Online Application – Montana Melin Foundation

920-858-6244
info@montanamelinfoundation.com

Date*
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Phone*
If you have just established residence in the past year, last address? Skip if this does not apply
Previous Address (if applicable)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long did you live there?
How long do you plan to reside at your present residence?
Place of Employment?
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone
Employer's Extension of applicable
Do other family members work?
- Yes
- No
Place of employment?
If unemployed, what was your last job?
Are you receiving any of the following?
- Unemployment
- Worker's Compensation
- Other?
If other, please specify
Amount? (Add all)
Have you applied for employment? If so where?
- Yes
- No
Where have you applied?
What areas of work are you seeking?
Assets: Please check all that apply
- Own a vehicle
- Have a place to stay
- Receive foodstamps
- Receive housing aid
- Receive child support
- Receive alimony
- Receive Medicare
- Receive help from my family
What are your monthly financial needs (including the estimated amount of need and a description of your long term or short term and options).
Have you considered or received assistance from any of the following?
- County Aid
- Church (or churches)
- Other charity or charities
Tax Returns*
Are you able to provide a copy of your tax return for the past 3 years?
- YES
- NO
List other charities here
Briefly explain the needs that you are asking the Montana Melin Foundation with?
Acknowledgement
I hereby affirm and acknowledge, by signing immediately below (or checking "Agree" and pressing the "submit" button to submit my application online), that all of the information I have provided in this application for Assistance are true and complete, and that any misrepresentation or omission may be grounds for rejection. I understand that all benevolence decisions regarding my application are at the full discretion of the Montana Melin Foundation. I also understand that The Montana Melin Foundation is a non-governmental charitable organization financed by the contributions of individuals. If The Montana Melin Foundation decides to provide me with benevolence assistance, I agree to be bound by all policies and standards of The Montana Melin Foundation regarding such assistance. Disclosure Notice and Authorization Regarding Consumer Reports and Investigative Consumer Reports I understand that a consumer report and/or investigative consumer report containing information concerning my character, general reputation, person characteristics and mode of living may be obtained in connection with my investigative report may be obtained at any time during the application process with the foundation. I understand that I have the right to request within a reasonable period of time disclosures as to the nature and scope of the investigation requested. I understand that before an adverse action is taken, based in whole or in part to the contents of the consumer report or investigative consumer report, that I will receive a free copy of the report, the name, address and telephone number of the reporting agency, and a summary of my rights under the Fair Credit Reporting Act. I hereby authorize the Foundation and/or its designated agents to procure a consumer report and/or in investigative consumer report on me for the purpose of evaluating me for employment, promotion, discipline, retention, assignment, reassignment, and to make an independent investigation of my background, including but not limited to, references, character, general reputation, personal characteristics, mode of living, personal interviews with those acquainted with me, past/present employment, education, credit, motor vehicle records, drug screening records, federal, civil, criminal, sex offender and other police records, including those maintained by both public and private organizations and all public records for the purpose of confirming information contained on my application, resume, or in the other supporting documentation and/or obtaining other information, which may be material to my qualifications. I hereby authorize and request, without any reservation, that any present or former employer, school, law enforcement organization, financial institution, division of motor vehicles, consumer reporting agencies having knowledge about me furnish any and all information in their possession regarding me, in order that my qualifications may be evaluated. I herby assert a telephonic facsimile and/or copy of this authorization shall be valid as the original.
By checking the box below, I agree to submit my application.*
- Agree, submit my application
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Montana Melin Foundation
738 County Rd KK
Kaukauna, WI 54130
920-858-6244
info@montanamelinfoundation.com

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