Education Grant Application Form Please complete in BLOCK CAPITALS using black ink. Information requested in this application form is the minimum required for a grant to be considered. Applicants can enclose additional information if necessary. 1.
CONTACT DETAILS
Full Name of Beneficiary (Applicant) (Person requiring Assistance) Title
Age
Date of Birth /
Address
Postcode Telephone number
Mobile number
Email address Lodge Name (if applicable)
2.
Lodge No.
MASONIC DETAILS OF NOMINEE OR QUALIFYING FREEMASON (if different from above)
Full Name Address
Postcode Relationship to Beneficiary Lodge Name
3.
Lodge No.
EDUCATIONAL BACKGROUND
Please give a brief outline of the reasons for your application?
Name of the university / educational establishment / professional body Length of course Educational outcome (qualifications) following completion of course
1
/
4.
PAYMENT DETAILS
To whom would the funds be made payable ?
INCOME
BACS Account Name
Beneficiary
Per a/m/w
Bank/ Building Society
Parent/Carer
Sort Code
Per a/m/w
Account Number
Partner/Spouse
Per a/m/w
Gross Income from employment Pensions State Benefits & Tax Credits Current Account balance Any other Savings/Investments TOTAL INCOME EXPENDITURE Mortgage/Rent Utilities (Electricity, Gas & Water) Other essential living expenses TOTAL EXPENDITURE
NET INCOME
Give details of any other Grant applications submitted or received? Eg MCF
Date
DECLARATION To the best of my knowledge the information I have provided on this application form is correct. If Durham Benevolence agrees to make a grant, this will be used exclusively for the purposes described in this application form. Signature Print Name Date
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Durham Education Committee meets quarterly (Feb, May, August and November) and applicants are informed of the outcome during the following month.
Please submit completed applications to: Education Committee Durham Benevolence Ltd 8 The Esplanade SUNDERLAND SR2 7BH
Tel No: (0191) 567 5365 Email: benevolence@pgldurham.org Website:
www.durhamfreemasons.org
For Office use only Sub Committee Decision Comment
Approved
ÂŁ
_______________ / Declined / Deferred
Date
Version 3 (July 2017)
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