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Contact Person and/or Reference
Purpose of Request: Using only the space below, please provide a brief, concise description of why assistance is needed, the specific use of the funds, means of implementation and who it will serve. Please attach copies, or email to firstname.lastname@example.org, of any supporting documents you are willing to share with the board that may help expedite the application process. The Board of Directors reserves the right to request additional information and or documents to help determine eligibility.
Please submit files in .pdf, .doc, or .jpg format, less than 10MB.
By typing your full name below you agree to the terms of the application process and state the information provided is true.
* By checking this box you agree that you have read the Terms of Application below.
Terms of Application: Funds are distributed based on individual need as assessed by members of the board of directors of the Maritime Workers Emergency Medical Fund. Funds are limited and are distributed annually on a first-come first served basis. Distribution of fund amounts are based on the annual budget as prepared by the organization. All applications are considered using a 60 day application and interview process from the date the application is received. All steps are taken to protect the privacy of the applicant. Applicants providing medical and personal information must agree to share the information willingly to the board and trust the information will be treated with respect and is kept confidential. Information is used only to determine need for one-time funding and by no means makes the Maritime Workers Emergency Medical Fund responsible for additional debt or liability of the applicant. Funds distributed to applicants are reported to the IRS by the 501 (c)3 organization.
Click below for a PDF version of the application, which can be completed and emailed or mailed for consideration.