Flagstone Benevolence Request
By completing and submitting this form, I acknowledge that...
• Submitting this form does not guarantee that I will receive assistance.
• Whatever assistance I receive is a one-time gift and I may not submit another request for a period of at least 6 months from today's date.
• The information I have provided below is accurate and true to the best of my knowledge.
Benevolence guidelines
Follow this link to read the guidelines set by our Benevolence Committee: www.flagstonecoc.org/BenevolenceGuidelines.htm
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Email *
Your answer
Phone *
Please enter the best phone number we can reach you at.
Your answer
Preferred method of contact
Are you currently employed?
Name of Employer (if currently employed)
Your answer
If married, is your spouse employed?
Name of spouse's employer
Your answer
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