Financial Assistance application form

"*" indicates required fields

Please confirm you meet the eligibility criteria below:
You must meet ALL the criteria listed below to be eligible.

Supporting documents

Please upload files, photos or scans of documents needed.
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Max. file size: 128 MB.
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          Applicant Details

          Name of lead applicant who must be directly involved in delivering the project. Co-applicants will also need to include contact details - please use the repeat function to repeat this section.
          Name of applicant*
          Address for correspondence*
          Please select county from DROP DOWN MENU by clicking on 'Aberdeenshire' and then clicking on your own county.
          Email*
          Marital Status*
          MM slash DD slash YYYY
          Are you registered disabled?*
          Are you registered blind?*
          Please detail all qualifications held, their status and the date you obtained them.
          Please enter a number from 0 to 20.
          Is your NMC PIN Number*
          Please give details of your employment history. Please include the name of the post held, your employer for each post & the dates you were in each post.
          MM slash DD slash YYYY
          If shared please give details of ALL those living at home and contributing to the household costs. Please include each person's NAME, DATE OF BIRTH, RELATIONSHIP TO YOU & THE PAYMENT THEY MAKE TO THE HOUSEHOLD.
          Please name any other charities that you have approached or had assistance from in the past 2 YEARS and the amount received. We routinely exchange information with other charities in our field.
          Please confirm by typing yes or no that you have uploaded copies of your latest bank statements at the start of this form.

          Details of monthly income - If an income type is not applicable to you please type N/A

          Please complete these details for both yourself and your spouse/ partner if applicable. The amount stated should be £ PER MONTH for each income type listed. Please complete the fields in the following way: Earnings (after tax): Answer: £ xxx Me / £ xxx Partner If you are single please complete only for yourself.
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Please complete for yourself and your partner if applicable: £xxx Me / £xxx Partner
          Drop files here or
          Max. file size: 128 MB.

            Details of monthly expenditure - If an expenditure type is not applicable to you please type N/A

            Please complete these details for both the amount spent per month and the amount in arrears per month if applicable. The amount stated should be £ PER MONTH for each expenditure type listed. Please complete the fields in the following way: Mortgage or rent: Answer: £ xxx Per month / £ xxx Arrears per month If you are not in arrears for an expenditure type then please only state the cost per month. PLEASE NOTE THAT NON ESSENTIAL EXPENDITURE WILL NOT BE TAKEN INTO ACCOUNT WHEN ASSESSING AN APPLICATION.
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please complete for the cost amount and arrears amount per month if applicable: £xxx Per month / £xxx Arrears per month
            Please state the monthly repayment and outstanding amounts for ALL your loans, credit cards or other liabilities / debts.

            Declaration

            • I hereby certify that the information contained within this document is a true record of my current situation. Information given falsely or deliberately withheld will invalidate the application and no payment will be made, or if already in payment, stopped. • I understand that all information provided by myself or someone acting on my behalf will form a manual and computer file both of which are registered under the Data Protection Act. • For verification purposes I understand that The Queen’s Nursing Institute may contact the Department of Work and Pensions, NMC, Local Authorities or my GP to confirm information stated on this form. In some instances the QNI may also request that a letter of referral be supplied to support the application. • Unless an objection is supplied in writing, information contained within this form may be shared with other charities in order to try to secure the help I require, and to protect the funds of the QNI.
            MM slash DD slash YYYY
            If the form has been completed by someone other than the beneficiary, please sign below.
            MM slash DD slash YYYY
            Anonymous use of application
            From time to time the QNI uses details of applications in completely anonymised form for general fundraising purposes and to continue our welfare work. All names and personal details are changed to ensure complete anonymity. Please tick box if you do not wish for your application to be used in this way.

            Data protection

            Your privacy is important to us, and we will NOT pass your details to any third party. The Queen's Nursing Institute will use the information provided on the application form to process the proposal and manage any funding awarded. We will also use the information to communicate with you on issues which we feel may be of interest to you. By providing us with your information, you consent to us using it for the purposes outlined above.

            Monitoring Form

            CONFIDENTIAL This form is used to gather information for the purposes of monitoring adherence to our equal opportunities policy only. Information will not be used for any other purpose.
            Please indicate your age group
            Gender
            Do you consider yourself to have a disability?
            Ethnicity
            This field is for validation purposes and should be left unchanged.
             

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