MKApplicationForm

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I understand that the mission of the Dorcas Ministries educational assistance programs is to provide financial aid to eligible applicants. This assistance is not intended to be an income supplement or to be provided on a regular basis. By accepting these terms and conditions, I give Dorcas Ministries permission to contact whomever necessary to verify my need, to make a responsible decision regarding my request for assistance, and to contact additional resources with regard to my request. This permission includes but is not limited to, landlords, mortgage companies, utility or other service providers, medical providers and pharmacies.


I also understand the information I have submitted will be used to verify my need, to negotiate on my behalf, and to provide the requested assistance. By submitting this application, I hereby acknowledge acceptance of these terms and conditions and declare that all information I have given Dorcas Ministries is accurate and complete to the best of my knowledge.


I understand that if I have given false information in this submission, my household and I will be barred from receiving future assistance of any type from Dorcas Ministries. Also, I understand that the incident may be shared with other organizations.

MARGARET KELLER EDUCATIONAL ASSISTANCE

Applicant Information

Applicant’s Name:

First Name: 

MI:

Last Name: 

Date: 

New Renew

Birth date:

Phone:

Cell: 

Current address:

Email: 

City: 

State: 

ZIP Code:  

Own Rent

How long? 

Employment Information

Current employer: 

Employer Address: 

How long? 

Supervisor: 

Phone: 

City: 

State:

ZIP Code: 

Occupation: 

Full Time Part Time

Annual income:   $ 

Single Parent Household:     Yes No

Family Members Living in Home

Name:

Age:

Relationship:

 

 

 

 

Education

School you are attending or planning to attend: 

Major:

Registration Date:  

Student ID#:  

Number of years you plan to attend: 

Contact Name:     

Email:  

Phone: 

Previous Education: 

School:                     

College

Technical School

High School

Graduate?

Yes No

Previous Education: 

School:                     

College

Technical School

High School

Graduate?

Yes No

Are you receiving financial aid? (scholarship, loans, grants, other)

 Yes No    Type of Aid:     $ 

Goal of this education experience:

 

Assistance Requested

o   Tuition         $ 

o   Books             $ 

o    Supplies      $ 

o    Exam Cost:   $ 

o   Travel Expenses         $ 

Miles Traveled for school each week: 

o   Childcare Monthly Fee:  $ 

Name of Child:

Birth Date:

Childcare Contact Name:

 

Name of Childcare Facility: 

Childcare Contact Phone: 

Childcare Contact Email: 

Reference (Non-Family Member)

Name:  

Home Phone: 

Cell Phone: 

Address: 

Email 

City: 

State: 

ZIP Code: 

Relationship: 

Gross Annual Household Income 

 

Your income

Spouse’s income

Other income

·  Salary including tips

·  Unemployment compensation

·  Social Security compensation

·  Child Support

·  Aid for Dependent Children

·  Alimony

·  SSI

Other Assets or Sources of Income

Food Stamps

Yes No   $ 

Medicaid for Children or Household

Yes No

Medicare for Children or Household

Yes No

North Carolina State Voucher for Childcare

Yes No   $ 

Monthly Expenses  

Mortgage

Clothing

Loans

Rent

Childcare

Credit Cards

Food

Cable

Life Insurance

Electricity

Car Payments

Medical Insurance

Gas

Travel Expenses

Car Insurance

Water

Home Telephone

Alimony/Child Support

Medical

Cell Phone

Auto Repair

       

Total Monthly Expenses

 

What dollar amount are you able to pay?   $          Yearly? Monthly?

Have you ever received Assistance from Dorcas Ministries?      Yes No

If yes, what kind?

 

If yes, when?

 

Please share why you are applying for financial assistance?

 

I certify that all information is true and complete to the best of my knowledge. I grant permission to Dorcas to verify this information. I agree to notify Dorcas if my financial status should change or if my child is no longer participating at the designated place for which I am receiving assistance.

 

                                                                                                                                                           

(Signature will be required at time of interview)                        Date of Signature

To submit the application, click Yes to accept the otherwise the application will not be submitted.

I accept the Terms and Conditions:        Submit this form on-line.

FOR OFFICE USE ONLY:

 

Date of interview:                        Date Processed:                                  Date Notified:                       

 

Assistance Awarded:                                                     Payable to:                                                      

 

Form 120309MK