Application Form

Instructions: Please complete the entire form and submit it online for approval. You may also print the application and mail the completed form to:

The Shirley Mae Breast Cancer Assistance Fund
PO Box 3265
Margate, NJ 08402

Once we receive and review your application, you will receive a phone call to verify your information and eligibility. Approvals take no more than two weeks. In many cases you will be notified within a few days.