PRELIMINARY APPLICATION

TO GET STARTED, FILL OUT THE QUICK PRELIMINARY APPLICATION HERE ON THE WEBSITE.

A REPRESENTATIVE OF THE GOVERNANCE COMMITTEE WILL CONTACT YOU WITHIN 24 HOURS TO ASSIST YOU WITH NEXT STEPS IN THE APPLICATION PROCESS.

SUBMISSION OF THE FULL APPLICATION AND SUPPLEMENTARY MATERIALS WILL BE NECESSARY TO BE CONSIDERED FOR BENEFITS.

Employee Name (*)

Employee Number (*)

Employee Email (*)

Employee Phone Number (*)

Employee Full Home Address (*)

Employee Work Location (*)

Recipient's Name (if different than employee)

Recipient's Relationship to Employee

Recipient's Home/Cell Phone Number

Recipient's Email

Describe the recent natural disaster, catastrophic event or serious illness that caused the personal financial hardship.(*)

Please answer these additional questions,
if you have not covered them in your previous answer.

Is this hardship related to the Model Coronavirus?(*)

Who was directly affected by the natural disaster,
catastrophic event or serious illness?(*)

When did the aforementioned event occur?(*)

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