Application for Assistance

Please Note: All information supplied is confidential and is only requested for the purpose of this application.

Personal & Contact Information

Purpose of application Grant Loan Either

Full Name

Enter your email address (to receive copy of your submission - and so we can contact you)

Date of Birth

Address

Contact Phone Number

Marital Status

No. of Dependants

Department

Grade

Additional & Financial Information

Are you a member? No Yes

Have you previously applied to the Society for assistance? Yes No

When?

Your Income (per week, eg 180)

Partner's Income (per week, eg 160)

Children Receiving Child Benefit (0 for none, 1 for 1 receiving benefit)

Any Other Income? Yes No

Additional Weekly Income

Reason for Application

IF your application is successful, the Society can pay via cheque or direct lodgement/EFT. If via direct lodgement, please include your BIC and IBAN below.

BIC

IBAN

Relevant documents (payslip, cover letter) optional

Average weekly expenditure

Please Note: All information supplied is confidential and is only requested for the purpose of this application.

ESB

Medical

Food

Telephone

Heating

Transport

Insurance

Other

Financial Commitment (Monthly)

Please Note: All information supplied is confidential and is only requested for the purpose of this application.