Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

I certify that I am a hospitality worker who has experienced: *

Loss of income due to Covid-19

Financial hardship due to Hurricane Laura

Financial hardship due to Hurricane Sally

Dates of Employment *

Start date

MM

DD

YYYY

*

End date

MM

DD

YYYY

Please read statements below and provide details . *

I understand that the Fund will take reasonable measures to protect my privacy. However, I understand that my anonymity cannot be guaranteed.

I understand that funds may not be available at this time, and that my application does not guarantee of approval of funds.

I have provided supporting documentation and agree to provide additional information that may be requested by the Fund Review Committee.