Gibsons Employee Assistance Fund Application

Gibsons' Employee Assistance Fund is to provide immediate financial assistance to employees who experience financial hardships resulting from a natural disaster.

A red asterisk (*) indicates a required field.

Employee Name:*

First NameLast Name

Age:*

Cell Phone Number:*

Area CodePhone Number

E-mail:*

Physical Address at time of flood:*

Street Address

Street Address Line 2

CityState

Zip Code

County/Parish:

Alternate Contact Name:*

First NameLast Name

Alternate Contact Phone:*

Area CodePhone Number

Relation to Contact:*

Your primary residence that was affected by the flood is/was:*

Owned by youRented by youLived in, but owned by someone else

Current Employment Status:*

Full timePart time

Total number of people living in the home, including you:*

Number of dependents NOT living in the home:*

Examples are children in college

Total household income level:*

Amount of water in home:*

Additional Comments regarding the impact, physical damage or financial need:

Please upload up to 6 pictures of your loss/damage:

Upload a File

I attest the information furnished above is true to the best of my knowledge. I also understand the Fund reserves the right to require and seek verification of information submitted on this application with my employer. Finally, I agree to confidentiality on the process and amounts granted to me through this employee grant process.*

YesNo

Address to which the relief check should be mailed, if approved:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code