Legal Documents Sign-Up Form

Please complete one form for
each person
requesting documents

Name of Sponsoring Organization

Please provide the name of the organization that directed you to Bethel Community Services.

CLIENT 1

Full LEGAL Name

Please provide your full legal name and not your nickname or common name. (i.e Please use Joseph and not Joe or Joey)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

A limited single-use access code will be emailed to you at the email address entered for use on the Faith to Fate website. This code is needed in order to by-pass the payment screen and to gather additional detail required to preparation your documents.

Are you covered under Medicare Part B?

Yes

CLIENT 2

Full LEGAL Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you covered under Meidcare Part B?

Yes

CLIENT 3

Full LEGAL Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you covered under Medicare Part B?

Yes