Pittsboro Baptist Church Benevolence Application
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Email *
Full Name:  *
Current Street Address:  *
City, State, Zip *
County:  *
Home Phone:  *
Cell Phone
Date of Birth *
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Current Residence:  *
Length of time at Current Residence:  *
List all people living at your current residence:
(Please also include name, age, employer or school and relationship to you for each person listed)
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Have you or anyone in your household received financial assistance from Pittsboro Baptist Church in the past? If so, who, when, and how much?


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What is your need and what specific help are you requesting? Please include account numbers and any other relevant information.

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What events led you to be in need of assistance (e.g., loss of job, unexpected bills, etc…)?

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When does your need require attention (e.g., due dates, termination of services, etc…)?

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What steps have you taken to resolve your current need prior to contacting Pittsboro Baptist Church?

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List all churches/agencies/organizations that you have contacted requesting assistance and outcome of request.

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List  your current and past employment for the last 3 years including the following information:

Employer Name, Full or Part Time, Title, Dates of Employment and Reason for Leaving

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List  your spouse or roommate's current and past employment for the last 3 years including the following information:

Employer Name, Full or Part Time, Title, Dates of Employment and Reason for Leaving

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Please Provide a photocopy of government issued photo identification card (e,g,, driver’s license, ID card, passport, etc..) by emailing it to pbccarefund@gmail.com


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Required

Release Information

I hereby authorize the release of information to Pittsboro Baptist Church’s “PBC Bowling Care Fund” committee members for the purpose of evaluating my request. I further certify that the information I have stated is true and correct. I understand that committee members may obtain any information deemed necessary to verify the information on this application and that false or incomplete information may subject me to denial of assistance and/or disqualification of future assistance. 

I give permission for the PBC Bowling Care Fund committee members to discuss my case with other agencies, businesses, churches, individuals, any any other deemed necessary to verify the application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible with these entities. 

I have read, understood, and agree to the provisions as stated. 

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Required
A copy of your responses will be emailed to the address you provided.
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