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I hereby acknowledge that I have read the RERF Eligibility Guidelines and to the best of my knowledge, believe that I may qualify for a Grant or, that the individual I am submitting on behalf of is eligible.

Employee Complete First & Last Name*

Employee Number*

Employee Email*

Employee Phone*

Employee Full Home Address, City, State, Zip*

Employee Full Work Location Address, City, State, Zip & Brand Name*

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*

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

When did the aforementioned event occur?*