Application FAQs Financial Assistance Application (no charge) APPLICANT INFORMATIONName*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Email* Phone*Name of Spouse/Partner*Does this person live at the same address as above?*YesNoPlease provide spouse/partner's address*CYCLE AND FINANCIAL INFORMATIONClinic or Adoption Agency*Infertility Diagnosis*Current Cycle-Out-Of-Pocket Costs (US $)*Prior Cycle Payments Owed (US $)*Total Infertility Costs (US $)*PERSONAL STATEMENTPersonal Statement*Please provide an explanation of your current and any prior infertility treatment(s) as well as your need for financial assistance. Please be as detailed as possible in describing your need for this scholarship.STATEMENTS AND SIGNATUREIn completing this application for financial assistance I understand and agree to the following: A. AGC awards one-time grants, the exact amount and frequency of which is at the discretion of AGC’s Selection Committee. B. If granted financial assistance, I agree to the possible publication of my name and/or likeness by AGC. C. All information submitted in this application is true and correct to the best of my knowledge. D. If requested, I will provide any and all additional documentation or information requested by AGC. E. I give permission to my clinic or adoption agency to release verification of being a patient/client to AGC. Applicant's Name*Applicant's Signature*Date* APPLICATION FEEProduct Name*Total $0.00 Prove You Are Human!