Employee Emergency Fund Request Form printable pdf download

Employee Emergency Fund Request Form

No information will be shared with a third party except for processing or tax reporting purposes if an award is

provided. Completed application materials will be retained by Creighton University’s Human Resources

Department.

Date of Application ___________________

Employee Information

Employee First Name ________________________________ Last Name_____________________________

Preferred Phone # __________________________ Alternative Phone # _____________________________

Home Address ____________________________________________________________________________

City ____________________________________ State ___________ Zip Code ______________________

Email Address ________________________________ Creighton Net ID _____________________________

Department/School ________________________________ Job____________________________________

If this application is being completed by a representative of the employee:

Representative First Name ______________________________ Last Name__________________________

Relationship to Employee _________________________________ Phone # __________________________

Email Address __________________________________________

Details of Emergency

1. Describe the circumstances surrounding the need for assistance. If possible, please include with this

application any documents substantiating or supporting your need for assistance.

2. What is the dollar amount needed to work through this emergency?

Employee Emergency Fund Request Form