HERO Act Program Form

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Sofia Moreno
State Treasurer
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Joined: Thu May 27, 2021 11:47 am



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Office of State Treasurer
San Andreas State Government
State Capitol, 1 Alta, Los Santos, SA

HEROES ASSISTANCE PROGRAM FORM


I. SUMMARY AND ELIGIBILITY
  • this program intends to address all the men and women who devote their lives to all the Public Safety agencies scattered across our great state of San Andreas. The objective is to provide payments to San Andreas Law Enforcement, Firefighters, and State Fire Marshals that could be affected with cancer, organ complications, post-traumatic stress disorder (PTSD), physical injuries or are in dire need of counseling.

    To be eligible for assistance under this section, firefighters or law enforcement agents must have;
  • 1.1 A current diagnosis of cancer, organ complications, posttraumatic stress disorder (PTSD), physical injuries or have been diagnosed within the year preceding their application, in which it should include documentation from their care provider of their diagnosis of cancer or heart disease.
  • 1.2 Employees must have completed the probationary period;
  • 1.3 Employees who are terminated are not eligible unless they are medically discharged;
  • 1.4 Employees must have completed at least ten years of service
  • 1.5 It is mandatory to provide the employee's PHMC medical record attached to be elligible for the program.
II. REQUESTER'S DATA
  • 1.1 Full Name:
    ANSWER

    2.2 Date of Birth:
    ANSWER


    2.3 Address:
    ANSWER

    2.4 Contact Number:
    ANSWER

    2.5 Agency:
    ANSWER

    2.6 Service History (Tenure):
    ANSWER
  • 2.2.1 I hereby confirm that the personal information provided is up-to-date:
    Mark "X" where applicable.

    [] Yes
    [] No
III. PROFESSIONAL'S INPUT
  • 3.1 Name of the medical examiner:

    3.2 Findings post-interview:
    Provide a summary of the interview with the patient to further clarify his/her current state.
    COMPREHENSIVE ANSWER




    3.3 Diagnosis (If any):
    Provide a summary of the findings that relate to the medical aspect in regards to the patient's status (physical/mental)
    COMPREHENSIVE ANSWER


    3.4 Plan of Action:
    Demonstrate the roadmap to be executed to provide care for the patient.
    COMPREHENSIVE ANSWER


    3.5 Financial Bid:
    Provide us with the details of your pricing and any aftercare arrangements within the price.
    COMPREHENSIVE ANSWER

    3.6 Estimated Length of the Program:
    COMPREHENSIVE ANSWER

    3.7 Signature of the examiner:
IV. DECLARATION OF AGREEMENT
  • I hereby declare that I have read and understood the Summary and Eligibility provided in this form by the Office of State Treasurer.
  • I authorize the State of San Andreas, to contact government agencies, past employers, educational institutions, and listed references in the course of investigating my background.
  • I authorize the State of San Andreas, to release all data gathered during the background investigation to public procurement management at the State of San Andreas for use in evaluating my government contract bidding form.
SIGNATURE
First Name Last Name
V. STATEMENT OF TRUTH
  • I hereby certify that the answers I have given are true and correct to the best of my knowledge and belief and that I understand and agree to the provisions, conditions, and restrictions herein or otherwise imposed.
SIGNATURE
First Name Last Name








((OOC Information))
((Bill: https://forum.gta.world/en/topic/56251- ... 1632488031 ))

((Please submit the application to: ((SUBMISSION BOARD)) with the title of "HERO Program - APPLICANT NAME"


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[b]Office of State Treasurer
San Andreas State Government
State Capitol, 1 Alta, Los Santos, SA[/b][/align]
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[align=center][size=150]HEROES ASSISTANCE PROGRAM FORM[/size][/align]
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[divbox=#516a6f][center][color=#FFFFFF][b]I. SUMMARY AND ELIGIBILITY[/b][/color][/center][/divbox]
[list=none][size=85] this program intends to address all the men and women who devote their lives to all the Public Safety agencies scattered across our great state of San Andreas. The objective is to provide payments to San Andreas Law Enforcement, Firefighters, and State Fire Marshals that could be affected with cancer, organ complications, post-traumatic stress disorder (PTSD), physical injuries or are in dire need of counseling.[/size]

[u]To be eligible for assistance under this section, firefighters or law enforcement agents must have[/u];[/list]

[list]1.1 A current diagnosis of cancer, organ complications, posttraumatic stress disorder (PTSD), physical injuries or have been diagnosed within the year preceding their application, in which it should include documentation from their care provider of their diagnosis of cancer or heart disease.[/list]
[list]1.2 Employees must have completed the probationary period;[/list]
[list]1.3 Employees who are terminated are not eligible unless they are medically discharged;[/list]
[list]1.4 Employees must have completed at least ten years of service[/list]
[list]1.5 It is mandatory to provide the employee's PHMC medical record attached to be elligible for the program.[/list]

[divbox=#516a6f][center][color=#FFFFFF][b]II. REQUESTER'S DATA[/b][/color][/center][/divbox]
[list=none]1.1 Full Name:
ANSWER

2.2 Date of Birth:
ANSWER


2.3 Address:
ANSWER

2.4 Contact Number:
ANSWER

2.5 Agency:
ANSWER

2.6 Service History (Tenure):
ANSWER

[/list]

[list=none]2.2.1 I hereby confirm that the personal information provided is up-to-date:
Mark "X" where applicable.

[] Yes
[] No
[/list]


[divbox=#516a6f][center][color=#FFFFFF][b]III. PROFESSIONAL'S INPUT[/b][/color][/center][/divbox]
[list=none]

3.1 Name of the medical examiner:

3.2 Findings post-interview:
Provide a summary of the interview with the patient to further clarify his/her current state.
COMPREHENSIVE ANSWER




3.3 Diagnosis (If any):
Provide a summary of the findings that relate to the medical aspect in regards to the patient's status (physical/mental)
COMPREHENSIVE ANSWER


3.4 Plan of Action:
Demonstrate the roadmap to be executed to provide care for the patient.
COMPREHENSIVE ANSWER


3.5 Financial Bid:
Provide us with the details of your pricing and any aftercare arrangements within the price.
COMPREHENSIVE ANSWER

3.6 Estimated Length of the Program:
COMPREHENSIVE ANSWER

3.7 Signature of the examiner:

[/list]
[divbox=#516a6f][center][color=#FFFFFF][b]IV. DECLARATION OF AGREEMENT[/b][/color][/center][/divbox]

[list=none]I hereby declare that I have read and understood the Summary and Eligibility provided in this form by the Office of State Treasurer.[/list]

[list=none]I authorize the State of San Andreas, to contact government agencies, past employers, educational institutions, and listed references in the course of investigating my background.[/list]

[list=none]I authorize the State of San Andreas, to release all data gathered during the background investigation to public procurement management at the State of San Andreas for use in evaluating my government contract bidding form.[/list]

[align=right]SIGNATURE
First Name Last Name[/align]

[divbox=#516a6f][center][color=#FFFFFF][b]V. STATEMENT OF TRUTH[/b][/color][/center][/divbox]
[list=none]
I hereby certify that the answers I have given are true and correct to the best of my knowledge and belief and that I understand and agree to the provisions, conditions, and restrictions herein or otherwise imposed.
[/list]


[align=right]SIGNATURE
First Name Last Name[/align]


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