Veterans Fund Application (Page 2 of 2) in pdf

Goodwill Industries of Northern New England

Veterans Fund Application

Name: ____________________________________________________________________________________________

Are you applying for yourself, spouse or parent: __________________________________________________________

Address: _____________________________________City: _______________________ State: _____ Zip: ___________

Phone: __________________________________ Email (if applicable): ________________________________________

Date of Birth: ______________________ Military service date(s): ____________________________________________

Did you serve in a combat zone? (please circle):

Yes

How can Goodwill help you?

__________________________________________________________________________________________________

Total Funds Requested: ______________________Gross Annual Income

:________________________

(for referral purposes)

Information for Business to be Paid (if more than one business, include information on additional paper)

Name:_______________________________________ Phone Number:________________________________________

Address: _____________________________________City: _______________________ State: _____ Zip: ___________

Would you like additional information on finding & keeping a job?: __________________________________________

Who referred you to the Fund? (please circle):

Vet Center

Goodwill Workforce Center

Self

Other

If Other, please list:__________________________________________________________________________________

Name of contact at referral source: ______________________ Phone Number for contact: ______________________

By signing this application, I acknowledge that I am formally requesting funds from the Goodwill of Northern New

England Veterans Fund and authorize Goodwill of Northern New England to discuss this application with any

representative of a Maine Vet Center or other referral organization.

___________________________________________________

______________________

Signature of Applicant

Date

Please include a copy of applicant’s DD214 or a Casualty Form for consideration.

Updated December 27, 2013

Veterans Fund Application Page 2