Applicant information

First name

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Last name

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Phone

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Phone type
Email address

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Address

Address

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Apartment, suite, etc. (optional)
City

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Country/region

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State

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ZIP code

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Background

Gender

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Ethnicity

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Languages

Co-Applicant information

First name

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Last name

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Phone

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Phone type
Email address

Enter a valid email address

Email type

Address

Address

Enter an address

Apartment, suite, etc. (optional)
City

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Country/region

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State

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ZIP code

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Background

Gender

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Ethnicity

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Languages
A.

Employee With You Fund.

An active employee may apply up to once a year for a grant after 90 days of employment. With a grant maximum being $500 per grant.

Employee Number

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Employment Start Date

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Employee Branch

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Employment Status

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Current Job Position

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Personal Phone Number

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Work Phone Number

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Personal Email Address

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Type of Emergency

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Amount Requested

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B.

Details of Emergency

Please answer the following questions completely. All information provided will be confidential. Financial disclosure is required.

What is the purpose of this request? (Describe the circumstances that led to the emergency need/extent of damage or suffering)

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When do you need the grant?

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Have you used up significant portions of existing assets to meet this emergency?

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Have you ever applied for a grant from this fund before?

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Will any of these expenses be covered by insurance?

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Other comments/information that would be helpful in reviewing this application? Please provide any additional information to help the committee make a recommendation

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C.

Supporting Documents Section

Supporting documentation is required and must be submitted with the application. Examples of documentation include past due utility bills, police/fire reports, invoices of funeral expenses, quotes for equipment or services, bereavement camp registration documentation, etc. Incomplete requests will not be processed.

Do you have any supporting documentation?

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If you answered yes to the above question. Please upload your documents here.

Description

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I certify that the information provided in this grant application is true and correct to the best of my knowledge. The Carnation Foundation shall not obtain any information that would constitute "protected health information," as such term is defined in 45 CFR 160.103, from Agape Care Group, Inc., or their wholly owned subsidiary or affiliate or any group health plan sponsored by one of the aforementioned parties. Any intentional misrepresentation of the information contained in this application will result in forfeiting this and any future grant application. I authorize the Committee administering this program to verify any assets needed to process my grant application. Furthermore, I understand that any grant I receive from this program will be treated as taxable income. I understand that The Carnation Foundation Committee will take reasonable measures to protect my privacy. However, I understand that my anonymity cannot be guaranteed. Do you acknowledge this statement?

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

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