FUNDING APPLICATION – Joseph Seridis Trust Fund

Applicant's First Name *Please supply applicant's first name.

Applicant's Surname *Please supply applicant's Surname.

Applicant's Date of Birth *

Please supply applicant's Date of Birth.

Applicant's Email Address *Please supply applicant's Email Address.

Applicant's Phone Number *Please supply applicant's Phone Number.

Street Address *Please supply applicant's street address.

Apartment, suite, etcPlease supply applicant's apartment or suite number.

City *Please supply applicant's Town/Suburb/City.

State *Please supply applicant's State.

Postal Code *Please supply applicant's Postal Code

Country Please supply applicant's Country.

Is the applicant being assisted with this submission? *YesNoIs the applicant being assisted with this submission?

Name of Person Assisting with ApplicationPlease supply the name of the person assisting applicant with application (if applicable).

Relationship to ApplicantPlease provide relationship to applicant (if applicable).

Person Assisting's Email AddressPlease provide the person assisting applicant's Email Address.

Person Assisting's PhonePlease provide the Phone Number for the person assisting applicant (if applicable)

Please select type of funding request *EquipmentHolidayPlease select from the following types of funding requests.

Applicant's Funding Request Detailed Description *

0 / 2000

Amount of assistance being requested is *Full AmountPart AmountPlease specify if the amount of assistance being requested is the Full Amount or Part Amount.

Amount of assistance being requested $ *Please supply the dollar amount for applicant's funding request.

Applicant's Personal History/Description of Needs *

Please supply information regarding applicant's history and description of needs.0 / 2000

Please state reasons why applicant requires assistance *

Please state reasons why applicant requires assistance.0 / 2000

Full Name (Author) Letter of Support *Please supply the name of the author of letter of support.

Position (Author) Letter of Support *Please supply the position for the author of Letter of Support.

Upload Letter of Support *

No file chosen

Upload Letter of Support. The following files types are supported only, jpg, jpeg, jpe, png, bmp, doc, docx, pdf, osxps and xps. Maximum file size 8mb.

Have you attempted to get funding from other funders? *YesNoPlease indicate if you have attempted to secure funding from other providers, or if not why you have not tried other funders.

If you have tried other funders, please provide details on why your application was unsuccessful

If you have tried other funders, please provide details on why your application was unsuccessful.0 / 1000

Does the applicant approve of this application submission? *YesNoDoes the applicant approve of this application submission?

Date of Application *

Date of Application