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GRANT INQUIRY FORM helping those in our industry most in need
C A R D
Individuals and couples with a personal gift of $500+ are recognized as a Flooring Family Fellow. 2025 PLEDGE: I am investing at the following level to assist individuals in the floor covering industry when they are fighting the hardest battles of their life:
Address:
State:
City:
E-Mail:
Zip:
$50,000 Is this gift a:
Date of Birth:
Phone:
#1 Have you or an immediate household family member worked in the floor covering industry for 5 or more years?
$15,000
$10,000
$5,000
Telephone: or
Position:
$500
Other
State:
City:
Zip:
Name:
If yes, name of person:
Name of company:
$1,000
Personal Gift
Address:
Note: Grant recipients must be currently employed in the flooring industry or not have left more than 5 years ago, unless there are retired or have a qualifying medical condition. No
$25,000
Corporate Gift
Company:
To help determine if you might qualify for assistance from our organization please answer the following three questions:
Yes
P L E D G E
I care about industry workers. Please put my donation to work right away to help the Floor Covering Industry Foundation step up its efforts to assist those in our industry suffering from catastrophic illness or severe disability.
We provide financial assistance to help with medical care, prescriptions, medical equipment, home repairs, shelter, food, utilities, and other basic needs for families who have a catastrophic or life-altering medical event. Name:
self-employed
Email:
Gift to be paid by: Credit Card: visit us online at fcif.org to complete this option
Company Phone:
Check - enclosed. Check # Number of years worked in the flooring industry: #2 Do you have a life-altering medical condition?
Please Bill Me ($100 minimum) starting on this date: Yes
No
Monthly
Quarterly
One-Time Only
Billing Address, if different from above:
If yes, please describe your illness, injury, or disability:
Bank Draft - monthly - attach a voided check
Please contact me about planned giving.
SIGNATURE:
Date: I would like my gift to be anonymous.
MULTI-YEAR COMMITMENT: Please renew - I would like to make the
#3 Is your household in extreme financial need? Yes No Please briefly describe your household income and other financial assets and your monthly expenses and medical bills. What assistance do you need to help you pay your bills or get medical treatment?
for the next
annual 10% increase
TRIBUTES: You may make contributions in loving memory, as a loving tribute to a dear one, or for any reason at all. Enclosed is my gift of
APPLICANT SIGNATURE:
same level or
years.
which is made in
memory or in
tribute to:
Please send an acknowledgment card to:
Date:
Name:
We will reply to all Grant Inquiry Forms within 10 business days. If you have not heard from us, please call 706.217.1183 ext 105 or email info@fcif.org. If we think you might be eligible for assistance, we will ask you to complete a full grant application. We encourage you to go ahead and review the documentation that will be required by visiting our website, fcif.org/grants-applications.
Address:
City:
State:
Zip:
FCIF is a 501(c)(3) non-profit. Gifts are tax deductible, given that no goods or services were received in exchange. Your donation is greatly appreciated!
Return this form to: FCIF, 855 Abutment Road #1, Dalton, GA 30721 • Fax: 706.217.1165 • Email: info@fcif.org
Please return this form to: Floor Covering Industry Foundation • 855 Abutment Road, Ste. 1 • Dalton, GA 30721 P: 706.217.1183 or 855.330.1183 • info@fcif.org • F: 706.217.1165 FCIF.org
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11” x 17” pdf 8.5” x 11 pdf
English 8.5” x 11 pdf Spanish 8.5” x 11 pdf
8.5” x 11 pdf
Individual 8.5” x 11 pdf Corporate 8.5”
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contact us ablackbourn@fcif.org 855.330.1183 fcif.org