Les Clefs d’Or Foundationof the Americas
Grant Application
Grant Eligibility Requirements
Active ConciergeApplicant term is defined as Concierge having held full time concierge position for a minimum tenure of twelve (12) consecutive months. Concierge working a minimum of 32 hours a week within United States, Canada, Mexico, Argentina, Brazil as a hotel concierge.Concierge Applicant has to have been employed full time within the last six months.Any professional or social affiliate member of the Les Clefs d’Or USA of the Americas, in good standing, as well as an immediate family member and/or significant other of the above defined member categoriesis also eligible.
Grant ApplicationSubmitted Date Month/Date/Year:______/______/______
Concierge’s Name: (Last) ______, (First) ______(Middle)______
Social Security or Federal Identification Number: ______
Home Address: ______
Email: ______Personal Tel: ______Work: ______
List Contact In Case of emergency: Name: ______Contact Nr: ______
How long have you been employed as a concierge? Years: ______Months______
Name Your Hotel Employer & Contact Nr: ______
Are you still working full time at this hotel: Yes______No ______
If No, how many months has it been since you worked there on a full timebasis:______
If the above criteria cannot be completely fulfilled by the applicant, please explain: ______
Is this Grant Application for you: ______Your Spouse: ______Significant other: ______
Dependent Child: ______Parent:______
Full Name of the Applicant: ______Relationship ______
State Your Reason for the Grant Request:
______
I attest that the above information is complete, correct, and true.
Applicant’s Signature______Date: ______
______
Note: The completed Financial Information Application and a Statementof Diagnosis from the attending physician with his/her name, address, and signature of physician, must be enclosed/submitted with the completed Application.Signature above authorizes Les Clef d’Or Foundation of the Americas Board to participate in needed information exchange with the designated parties above with the intent of assisting
the Foundation in making eligibility determinations. These benefits are available to all qualified applicants regardless of race, creed, religion, national origin or sexual orientation.
Submit your Application to the LCD Foundation of AmericasChairs, below:
Olga S. Pierce, ChairGinny Thomason, Chair
Email: ospierce&conciergeunlimited.comEmail:
Mail: c/o Concierge Unlimited International5920 Bond Court, Alexandria, V22315
20 N. Wacker Drive, Ste. 1730 Chicago, IL 60606Tel: 703-971-5272
By 24hr Fax: 312-220-0525 Tel: 312-220-0500
GRANT APPLICATION FINANCIAL INFORMATION continue
ASSETS
Checking Account: $______$______
Savings Account:$______$______
Investments:$______$______
Stocks/Bonds $______$______
Business Assets:$______$______
LIFE INSURANCE$______$______
Cash Value: $______$______
TOTAL: $______$______
MAJOR MONTHLY EXPENSES
Mortgage:$______Assessment $ ______
Rent:$______Bank Loans:$ ______
Transportation: (Gas, tolls, fares)$______Car Payments$______
Day Care: (children, senior, disabled) $______Child/Spousal Support (owed):$______
MEDICAL DEBTS
Medical Bills in Collection:
To WhomInitial TotalBalance DueMonthly Payments
1)______$______$______$______
Outstanding Medical Bills:
To WhomInitial TotalBalance DueMonthly Payments
1)______$______$______$______
Projected Medical Expenses:
To WhomInitial TotalBalance DueMonthly Payments
1)______$______$______$______
Additional Monthly Expenses:
To WhomInitial TotalBalance DueMonthly Payments
1) ______$______$______$______
Unexpected Expenses:
To WhomInitial TotalBalance DueMonthly Payments
1) ______$______$______$______
OTHER MEDICAL EXPENDITURES:______
I attest that the above information is complete, correct, and true.
Applicant’s Signature______Date:______
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