Application Form













    Please read the following important information carefully before completing this form:

    • You must certify and demonstrate that you have an immediate and heavy financial need that necessitates assistance.
    • You must certify that you have no other source of funds to cover this hardship expense/financial need.
    • It is recommended that you be a current Alorica employee in good standing OR have a sponsor who is
      an Alorica employee in good standing. Once more, your sponsor must provide you with a written recommendation.
    • However, if you are an employee and NOT in good standing, you may still apply provided you include an explanation of your status in this application.



    REASON FOR HARDSHIP REQUEST

    I hereby request assistance in accordance with the MLBA Application for Assistance Guidelines. I am an Alorica employee in good standing (or provided an explanation why I am not) or have attached a written recommendation from my Alorica sponsor and the appropriate documentation (if required) as proof for my assistance request.

    Please explain your situation and specify what the funds will be used for: (If it is an immediate family member who is ill or injured, please note the relationship of the person to you)


    Please upload supporting documents:

    Supports the following uploads DOC,TXT,PDF,JPEG,PNG


    Please attach documentation to support your request. The list below provides information on appropriate documentation for each potential case:

    1) Unpaid medical expenses for self, spouse or qualified dependent and do not have insurance that pays for such expenses. The individual must demonstrate a plan to payoff such medical expenses which MLBA may assist in.

    Appropriate documentation includes:

    • Copies of medical bills (dated within the last 60 days)

    • Payment plans

    • Explanation of Benefits (EOB) documents from the insurance company (if any). Insurance documents/statements should include patient name, service dates and insurance payment information.

    2) Funeral or burial expenses for deceased parent, spouse, child or qualified dependent.

    Appropriate documentation includes:

    • Copies of funeral home and cemetery bills/estimates.

    • Explanation of Benefits (EOB) documents from the insurance company (if any). Insurance documents/statements should include deceased’s name, service dates and insurance payment information.

    3) Natural disasters e.g. typhoon

    4) For organizations requesting financial assistance:

    • You must be a registered and approved nonprofit organization

    5) Any other hardship due to unexpected, unforeseen circumstances not within the applicant’s control as determined solely in the discretion of MLBA.

    Have you received an MLBA grant before?
    YesNo
    If so when?

    Please note that MLBA guidelines state that more than one grant in any given calendar may not be granted.




    MM/DD/YYYY Format

    Payee Contact Information:




    *Please note if approved MLBA will only pay third party vendors directly for individual grants and not the individual grantees themselves unless approved by the MLBA Executive Board.

    *By checking the following, you understand that MLBA will be contacting third party vendors and other persons to verify and collect information related to your application. Check here if you accept these terms.

    PARTICIPANT CERTIFICATION, ACKNOWLEDGMENT AND AGREEMENT

    I certify that the information and supporting documentation that I have provided is complete and accurate. I have read and agree to the MLBA Application for Assistance Guidelines. I certify that if funds are requested, the amount of distribution requested above is not in excess of the amount necessary to satisfy the financial need described above, and that I have previously obtained all distributions and non-taxable loans available to me. I have viewed my chapter’s resource list (if one is provided by my chapter) and exhausted all of my resources. I agree to provide the MLBA Administrator with evidence of the existence of the financial need and the amount necessary and other documentation requested to satisfy such need upon request.

    I understand that the MLBA Chapter Board (if any) and/or the MLBA Executive Board will review my application and will determine whether I qualify for the amount requested. I understand that failure to provide complete and accurate information may disqualify me from receiving any funding.



    By typing in your full name above you are digitally signing this form.