Apply for support with utilities

Before applying, you must read the Qualifying Criteria. Download it by clicking here.

Contact Information
Name *
Name
Address *
Address
Primary Phone *
Primary Phone
Home Phone
Home Phone
Qualifying Criteria
Please confirm that you have read the Qualifying Criteria (link above) and that you believe that you are eligible for this service. *
You understand that we DO NOT discriminate against race, gender, sexual orientation, or religious preference. *
To qualify for assistance you must be a legal resident of the United States. Are you a legal resident of the United States? *
Support for services must be domestic and local (within 1 hour radius). Except where there are no qualified MDs within 1 hour driving radius. Are you applying for domestic and local support? *
You must have verifiable relevant diagnosis as reported by a board certified medical doctor practicing in the United States. Can a board certified medical doctor practicing in the United States validate your condition? *
Your treatment plan must be recognized through generally accepted oncologic practices such as those recommended in the National Comprehensive Cancer Network (NCCN) guidelines. Does your medical care provider employ generally accepted oncologic practices such as those recommended in NCCN? *
You must be receiving treatment for management of relevant illness. Are currently receiving treatment for the management of cancer? *
At home oral treatment is not covered under this program. Are you receiving treatment at an established treatment location, including outpatient locations? *
Must be able to redeem offering within 3 months from application. Should a gift be granted, will you redeem your gift within 3 months? *
Do you give Chamblu permission to contact your medical care provider ONLY for the purpose of obtaining the required signature and License Number? *
Enter your Physician's Name, the Hospital/Practice Name and their Phone Number.
Any required travel by a permitted accompanying non-patient (supporter), requires that the supporter remains with the patients at all times. I.e. Supporter may not leave clinic / hospital to “run errands” after depositing patient. Will you require a travel companion? *
Your household annual income must be less than $50,000/year. Does your household earn less than $50,000/year? *
Internal Use Only
The next 6 questions are for Chamblu internal use only. The information you provide helps us improve our value to you. Chamblu does not discriminate against Race, Religious, Sexual Orientation, or Gender.
What is your gender?
What is your marital status?
Please specify your ethnic or cultural background.
What category best describes your job function?
Do you have children?