Full Name: Date of Birth: Street Address: City: State: ZIP: Your Cell Phone: Your E-mail:
Marital Status: SingleMarriedSeparatedDivorcedWidow(er)
Employer Name: Position: Duration: Which is your employment level? Full-TimePart-TimeSeasonalUnemployed
Do you regularly attend a church? YesNo
Do you have relatives living close by? YesNo
Do you receive government assistance? YesNo
Have you received assistance from other churches in the past year? YesNo
Have you received assistance from other organizations in the past year? YesNo
Your total monthly income (all sources, including above) $
What specifically are you requesting from Cornerstone Chapel?
If you are requesting bill payment, you must supply the following information:
Company Name: Dollar Amount Requested: $ Account Number: Bill Mailing Address:
What current life circumstances led to this need? (Explain in detail.)
I authorize Cornerstone Chapel and its representatives to contact all necessary parties to obtain or share information regarding this request.
I understand that as a part of this process, the volunteer I meet with will be contacting me by phone to follow up on my spiritual needs. I understand that Cornerstone Chapel will be contacting me with financial decisions.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Benevolence Application
Agree & Sign