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Hardship Application

Section 1: Employee Information

Are you a current DPM Employee?*

YesNo

First Name*

Last Name*

Email Address*

Home Address

Address*

City*

State*

Zip or Postal Code*

Country*

Primary Phone *

Work Phone *

Where do you work? *

Fast FoodConvenience StoresCar WashCorporate Office

Store Name*

State*

City*

Date of Hire *

Position *

Average Hours Worked Per Week *

Average Bi-Weekly Paycheck *
$-USD

Do you have a bank account? *

YesNo

How many people are in your household? *

How many people in your household do you financially support? *

List the relationship(s) and age(s) of the household member(s) you help support.*
Example: Son (15), Daughter (20), Mom/Dad (52), Wife/Husband (43)

What is your total annual household income? * $-USD

Gender *

FemaleMaleNon-BinaryDo not wish to report

Ethnicity (for statistical use only) *

American Indian / Alaska NativeBlack / African AmericanAsianHawaiian / Pacific IslanderHispanic / LatinoWhite / CaucasianMulti-RacialDo not wish to report

Other (please describe)

What is your marital status?

Single, never marriedMarried or domestic partnershipWidowedDivorcedSeparatedDo not wish to report

Age *

Section 2: Beneficiary Information

"Beneficiary” means the employee or immediate family member for whom the grant application is being submitted; “Employee” means a DPM employee and affiliated entities; and “Immediate Family Member” means spouse, children and/or parents of the employee who reside in the employee’s household.

Is the Beneficiary the same as the applicant?*

YesNo

If no is selected, please fill in the boxes below

Name:

Relationship:

Section 3: Request For Emergency or Hardship Assistance

Emergency or Hardship Situation. *
Serious injury / Major life-threatening illnessNatural Disaster: hurricane, Earthquake, Wildfire, tornado, Flood, Tsunami, FireAccident involving a common carrier (buses, trains, Ferry, Plans, Or trucks)Exceptional medical expense: hospitalization, impairment, diseaseDeath of employee or immediate family memberScholarships

Amount Requested (Max $1,000 USD) * $-USD

Please describe your emergency or hardship situation. *

Please detail what the funds will be used for. *

Section 4: Supporting Document / Media

Please read instructions below and upload the appropriate documentation:

For Serious injury / major life-threatening illness & Medical: Upload hospital/doctor letter of diagnosis AND medical bills Medical Bills must display amount due and your name.
For Natural Disaster: Upload proof of loss (photos, news article, etc.) AND insurance claim, repair bill, invoices or listings for homes/vehicles. Invoices, bills, vehicle invoices must display the amount due and your name.
For Accident: Upload proof of accident, insurance claims, police report, items that need assistance. The amount that you are requesting must be reflected with your name on invoices/claims.
For Death: Upload death certificate, hospital confirmation or news story, itemized funeral home invoice listing costs. Invoices must be billed to you and have amount due.
For School Supplies & Scholarships: Upload proof of fees. Must display amount requesting and all documents must reflect your name.
For Other Emergency or Hardship: Upload any supporting documents of proof for your request for assistance. Must display amount requesting and all documents must reflect your name.
ALL REQUESTS REQUIRE BACK-UP DOCUMENTATION THAT DISPLAY THE AMOUNT THAT YOU ARE REQUESTING AND YOUR NAME. IF YOU DO NOT PROVIDE THIS, YOUR CASE WILL BE DELAYED.
(Document types allowed: PDF, JPG and PNG Max Size 3mb)

Have you or the beneficiary requested any other support or assistance for this emergency situation (examples include other charitable organizations, insurance, government aid programs, or federal, state or local assistance)?*

NoYes

If "Yes" fill below info

Where applied

How much received? $USD

Section 5: Maji Foundation Hardship assistance

In the last 12 months have you or the Beneficiary applied for a grant from the Maji Foundation hardship assistance prior to this application?*

YesNo

How did you hear about this Emergency Fund? *

Section 6: Application Sponsor

If the employee is employed by DPM or its affiliated entities, this application must be sponsored by an above restaurant leader / above store leader / supervisor.

Please enter your sponsor details for your case to be processed. Not providing a sponsor will cause your case to be delayed.

Sponsor First Name

Sponsor Last Name

Sponsor Title

Sponsor Primary Phone

Sponsor Email Address

Add Personal Message (optional)

Section 7: Employee Certification

U.S. Applicants: I certify that to my knowledge I am in compliance with all laws, statutes and regulations restricting U.S. persons from dealing with any individuals, entities or groups who are subject to economic sanctions imposed by the U.S., such as countries subject to embargoes or groups of individuals, such as terrorists and narcotics traffickers.

Non-U.S. Based Applicants: I certify that to my knowledge, that I do not deal with any individuals, entities or groups subject to economic sanctions imposed by the U.S., such as countries subject to embargoes or groups of individuals, such as terrorists and narcotics traffickers.

In connection with my Application for a Maji Foundation Hardship assistance grant, I agree to provide my sensitive personal data and/or personal data under the General Data Protection Regulation (“GDPR”) to the Foundation. I consent to the processing and storage of my sensitive personal data and/or personal data contained in this Application for verification purposes and the potential disbursement of a grant from the Maji Foundation Hardship assistance. I further consent to (i) the transfer and storage of sensitive personal data and personal data in the United States (and Canada) ; and (ii) allowing us to share with the employees of the Maji Foundation Hardship assistance Administrator, DPM and affiliates, the Maji Foundation Hardship assistance Grant Allocation Committee Members and/or any of their respective designees for the sole purpose of evaluating and assessing your Application and disbursement of a grant from the Maji Foundation Hardship assistance, You have at any time the right to request access to, modification of or destruction of the data by sending an email to majifoundation@dossaniparadise.com.

All Applicants: I further certify to the Foundation that the information contained in this Application is true and correct. Additionally, if I am submitting this application on behalf a Beneficiary, I certify to the Foundation that the Beneficiary is my Immediate Family Member

I consent to the above certification

Checking the box means you consent to the disclosure of the information contained in this application to the Application Sponsor set forth in Section 6 of this Application.

I consent

By accepting a gift from the Fund, I agree to provide copies of the following materials if requested by the Foundation: receipts demonstrating the emergency or hardship, my expenditure, and documentation illustrating my relationship to the Beneficiary, if I am submitting this application on behalf of an Immediate Family Member.

I agree to the above statement

Section 8: Beneficiary Certification

I certify to the Foundation that (i) the Beneficiary is my Immediate Family Member and (ii) the information contained in this application is true and correct.

I agree to the above certification

Consent

If approved for a grant, I further agree and consent to the use and publication of my name, image and the details of my emergency hardship described in the Maji Foundation Hardship assistance Application in videos, print, web postings, digital, audio, electronic, or other medium or format by the Maji Foundation in order to assist in its educational, promotional, public relations and fundraising goals. By signing this authorization and consent, I hereby waive any right to compensation for such uses, and I and my successors and assigns hereby hold the Maji Foundation, its administrators, directors, officers, employees or agents and related entities, and assigns harmless form and against any claim for any injury, and any compensation, resulting from the activities authorized by me above. I understand that I have the right to revoke this waiver, and to revoke my consent and authorization in this form, at any time, by notifying the Maji Foundation.

I consent

In connection with my Application for a Maji Foundation Hardship assistance grant, I agree to provide the sensitive personal data and/or personal data of the beneficiary and/or myself under the General Data Protection Regulation (“GDPR”) to the Foundation. I consent to the processing and storage of such sensitive personal data and/or personal data contained in this Application for verification purposes and the potential disbursement of a grant from the Maji Foundation. I further consent to (i) the transfer and storage of sensitive personal data and personal data in the United States [and Canada] ; and (ii) allowing us to share with the employees of the Maji Foundation Hardship assistance Administrator, DPM and affiliates, the Maji Foundation Hardship assistance Grant Allocation Committee Members and/or any of their respective designees for the sole purpose of evaluating and assessing your Application and disbursement of a grant from the Maji Foundation Hardship assistance, You have at any time the right to request access to, modification of or destruction of the data by sending an email to majifoundation@dossaniparadise.com

I understand and accept the above statement

E-Signature. Please type your full name *

Today's Date *