Language
English (US)
Spanish (Latin America)
Pay it Forward Assistance Referral Agency
This program is a one-time grant based on a referral from a professional reference (licensed counselor, social worker, licensed case manager, social services advisors, physician, clergy/minister, attorney, employer, or 501c3 agency).
Agency/Organization Data
First Name
*
Last Name
*
City
*
Eligible State(s)
*
Oklahoma
Virginia
Zip Code
*
Phone Number
*
-
Area Code
Phone Number
Name of Company/Employer?
*
Job Title
*
Please Select
CEO
HR Administrator
Licensed Counselor
Social Worker
Licensed Case Manager
Clergy/Minister
Attorney
Physician
Social Services Advisor
501c3 agency
Email
*
example@example.com
NPI/ID/License Number/EIN (ENTER 0000 IF NO NPI/ID/LICENSE AVAILABLE)
*
Client Data
Client's Full Name (First, Last)
*
Explain your client's current situation?
*
Client's Email Address
Client's Phone Number
*
Is the client a US citizen?
*
Yes
No
Upload proof of US citizenship (state ID, drivers license or passport)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Client's State of Residency
*
Oklahoma
Virginia
Does the applicant have a history of violent crime and/or a felony?
*
Yes
No
Does the client have other means of financial assistance?
*
Yes
No
Requested Assistance
Select A Program:
*
Pay It Forward - Oklahoma
Pay it Forward - Virginia
Resume Review/Writing Assistance
Attend a Resume Workshop (Virtual)
Adopt-a-Family Winter Drive
Acknowledgements
Verification
*
I hereby verify that the above information is true and correct to the best of my knowledge and belief.
Please verify that you are human
*
Save
Submit
Please allow 2-3 business days for processing. If you have questions or concerns, please contact our office at support@goalsiniiative.com.
GOALS INITIATIVE, INC does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, gender, age, height, weight, physical or mental ability, veteran status, military obligations, and/or marital status.
Should be Empty: