Application For Funds

First Name*

Last Name*

Street Address*

Address Line 2

City*

State*

Zip Code*

Phone Number*

Email Address*

Confirm Email Address*

SSN*

How long have you worked in the Maritime Industry?*

Years

Amount Requested*

How are you associated with the Maritime Industry?*

Texas county where employed*

Purpose of Request: Please provide a brief, concise description of why assistance is needed, the specific use of the funds, means of implementation and who it will serve. Please attach copies of any supporting documents you are willing to share with the board that may help expedite the application process. The Board of Directors reserves the right to request additional information and or documents to help determine eligibility.

Purpose of Request?*

By checking this box, you agree to the terms of application below and certify that all information you have provided is true, complete, and accurate to the best of your knowledge.

Terms of Application: Funds are distributed based on individual need as assessed by members of the board of directors of the Maritime Workers Emergency Medical Fund. Funds are limited and are distributed on a first-come first served basis. Distribution of fund amounts are based on the annual budget as prepared by the organization. Every effort will be made to process the application in a timely manner. All steps are taken to protect the privacy of the applicant. Applicants providing medical and personal information must agree to share the information willingly to the board and trust the information will be treated with respect and is kept confidential. Information is used only to determine need for one-time funding and by no means makes the Maritime Workers Emergency Medical Fund responsible for additional debt or liability of the applicant. Funds distributed to applicants are reported to the IRS by the 501 (c)3 organization.