Goodwill CARES

Employee Information

First Name *

Last Name *

Preferred Name

Address

City

State

ZIP Code

Cell Number

Work Number

Home Number

Email Address *

Work Information

Position *

Work Location *

Department *

Are you a full time or part time employee? *

Full Time

Part Time

Employee Hire Date *

Request Information

Have you ever applied for the Employee Emergency Assistance Fund in the past? *

Yes

Have you applied for Goodwill CARES in the past? *

Yes

This request is the result of: *

Other

Housing *

Own

Rent

Unhoused

Please explain in detail the nature of your request *

Supporting Documents *

Upload supporting documents (PDF, DOC, JPG, PNG, XLS)

Expenses *

Please list all monthly expenses.

Actions	Description	Amount (USD)
		$

Do you live alone? *

Yes

Have you sought assistance from any other local, state or federal agencies? *

Yes

Consent to Release/Obtain Information

Please provide below the following information to authorize Goodwill Industries of NWNC to release information to and/or obtain information from any person regarding your hardship.

Actions	Name	Relationship	Phone Number
No consent contacts added. Click 'Add Contact' to authorize information sharing.

Employee Acknowledgement

PLEASE NOTE: All pertinent information relating to this request submitted by the employee, as well as by Goodwill, will be presented to those on a need-to-know basis so that the proper decision can be made. The individuals who receive this information shall keep all information strictly confidential.

I hereby acknowledge that I will be responsible for any taxes due on funds received.

I hereby certify that the information in this application is true, correct and complete, and that I am requesting assistance because of a significant financial burden which is not covered by insurance or any other sources.

I hereby acknowledge that providing my name below serves as my electronic signature for this document.

First Name *

Last Name *

Date *