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Employee Assistance Fund Application
Employee Assistance Fund Application
Employee Name
*
Department
*
Position
*
Date of Hire
*
Amount Requesting
*
I am a CEO employee and am requesting assistance due to an unexpected hardship in the amount of:
Reason for Request
*
Uninsured loss caused by fire or other disaster
Victim of a crime
Unexpected expenses due to illness
Death in the family
Loss of family income
Other
Please provide a brief summary of your hardship situation:
*
Date
*
MM slash DD slash YYYY
Δ
