BENEVOLENCE

Employment Information

“Please complete the form below”

Your Current Employer, Length of time, Full/ Part-Time or Seasonal?

Your Previous Employer, Length of time, Full/Part-time or Seasonal

Your Spouse or Partner Current Employer, Length of time, Full/Part-time or Seasonal

Your Spouse or Partner Previous Employer, Length of time, Full/Part-time or Seasonal

Are there any other adults in the household currently employed?

Yes

No

Name, Relation to you, and Monthly Contribution?

You must give the name, relation, and monthly contribution of every adult that is in your household currently employed.

If you are currently unable to work, please state the reason(s):

Is anyone in your household unemployed due to disability? Explain:

Is anyone in your household receiving disability benefits? Explain:

Do you or anyone in your household have a history of addictive behavior (gambling, alcohol, drugs, etc.)? Explain: