Application Form

Provincial Grand Charity of Derbyshire Application for Financial Assistance Specimen Only	Prov use only Date Ref No
Applicant for whom assistance is sought Name: Address: Tel. No.	Date of Birth
Details of affinity with Freemasonry
Lodge supporting application Master Lodge Member responsible Address Tel. No.	Signature
Brief Statement of present circumstances and need for help. (note 2)
Estimate of help suggested Immediate requirement Ongoing support
Any other helpful information (Note 3)
Date of Application
Date of Petitions Committee Meeting Action
Notes: 1.The Brother presenting this application should complete the form as far as possible, obtain the Master's signature and send it immediately to the Secretary of the Provincial Grand Charity. Supporting documents may be attached if helpful. Action taken may be direct or could include forwarding to more appropriate Charities. 2.This section should contain details of applicant's current weekly/ monthly income and outgoings, available bank or building society balances and particulars of any other investments, property owned etc. 3. Please state whether any help is available from relatives. It would help if applicants could indicate its purpose when they request a form, as there are different colours for different purposes.