Partners Helping Partners Application

Name Name * Title First Middle Last Suffix
Last 4 of SSN: *
Department: *
Email: *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Preferred Contact Method: *
Please describe the situation that's causing hardship: *
What steps are you taking to help yourself through this situation? *
Amount Requested: * $ Dollars . Cents
Please provide any supporting documentation to better help the committee in making a recommendation:
Please provide an itemized listing of what the requested money will be used for. Please attach Invoices/Statements that include the contact information for these bills:

Attach Files
Have you received or are you currently receiving assistance from any other organizations (ex.- Worker's Compensation, Short-Term Disability, Long-Term Disability, Insurance, State/Federal Agencies, Non-profit Agencies, Fundraising Efforts, or any other entity that is assisting you with your financial hardship)? If so, please list and/or describe below:
Have you received assistance from Partners Helping Partners in the past? *
Please provide any additional information to better help the committee make a recommendation. Please note that you are not required to provide personal information that would prove embarrassing or cause added stress. However, the better the committee understands the events that have occurred, the better they will be able to evaluate your specific request.

With my signature I understand and agree that filling out and submitting this application there is no guarantee of approval. I represent that all information provided in this application is true and correct. I understand that any false statement or omission of material facts may result in dismissal of my application.

I understand that Moore’s Electrical & Mechanical Construction, Inc. and the committee will take reasonable measures to protect my privacy.

I understand that funds may not be available at this time, and that my application does not guarantee approval of funds.

My signature below means that I have read, understand, and agree with the statements above.
Please sign: *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
For Office Use Only:
Application #:
Committee Comments:
Approved Not Approved at this time

Partners Helping Partners Application

Partners Helping Partners Application

For Office Use Only: