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INFORMATION

If you would like to nominate the family of a fallen or injured Law Enforcement Officer to receive a Christmas Shopping Spree from LEO Only, please fill out this application. Submission of this form does not guarantee any benefit to the applicant, nominated person(s), or any other individual.

Please understand that we want to help as many families as possible within our budget, however, LEO Only reserves the right to approve or deny any application without verbal or written response to the applicant, potential beneficiary, or any other individual. All information provided on this application will be verified.

By providing the information below, you have verified that the potential beneficiaries are willing recipients, and have authorized you to provide their information. Any incorrect or missing information will automatically void this application.

Thank you for your continued support and stay safe.

PERSON COMPLETING THIS FORM


Name:*
E-Mail:*
Telephone:
-

NOMINEE INFORMATION

Name of Fallen/ Injured Police Officer:*
Police Officer's Agency:*
End of Watch:
Name of Spouse or Closest Family Member:*
Their Telephone:*
-
Address:*
Names and Ages of Children:*

NOMINEE INFORMATION

Brief Reason for Nomination:*

AGREEMENT

By submitting this application, you agree to indemnify, defend, and hold LEO Only and its partners harmless, from any and all claims or causes of action, which you may now or hereafter have against LEO Only and its partners, which may at any time arise as a result of negligence or any act, or failure to act, or thing occurring in, or arising out of, the information provided on this application.

I further expressly understand and agree the foregoing indemnity, release, and waiver, is intended to be as broad and inclusive as permitted by the law of the State of Pennsylvania, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and effect.
I agree to the above terms:*
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