PRCW Tip Jar Program

Please make sure you have read through the Eligibility Requirements in the link bellow and if you believe that you are eligible, please fill out the application below making sure to include the required supporting documents.

Applicant Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Employment History

Name of Current or Most Recent Employer

Job Title

Supervisor's Name

Phone Number of Current or Most Recent Employer

Are you still employed at this business?

Yes

Hardship Description

Description

Type of Assistance

General

Psychological Assistance

Type of Psychological Assistance

*services available while funds last

Ammount of Financial Assistance Rquested

Please enter the requested grant amount. Note that PRCW Tip Jar Program grants typically have a maximum of $100.

Agreement and Certification

I authorize the PRCW Tip Jar Program to investigate my background and qualifications for purposes of evaluating whether I am qualified for the grant for which I am applying. I understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for a grant will not be processed further.

I certify that all information is valid and complete and authorize the PRCW Tip Jar Program to verify any of the above information as deemed necessary. I certify that I have reviewed the Eligibility Requirements and that, to the best of my knowledge, am eligible to receive a grant from the PRCW Tip Jar Program. I understand that, in the event the PRCW Tip Jar Program awards me a grant, I may be required to provide documentation regarding the use of the grant funds.

PRCW Tip Jar Program

Applicant Information

Employment History

Hardship Description

Agreement and Certification

In order to qualify for the PRCW Tip Jar Program, you must satisfy all of the following requirements:

SELECTION CRITERIA