NameThis field is for validation purposes and should be left unchanged.Name(Required) First Middle Last Other Members of Household:(Required)First NameLast NameRelationship Add RemoveAddress(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone Number(Required)Applicant's Name of EmployerApplicant's Name of SupervisorApplicant's Employer Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Applicant's Employer PhoneSpouse’s Name of EmployerSpouse’s Name of SupervisorSpouse’s Employer Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Spouse’s Employer PhoneSpouse’s Name of EmployerSpouse’s Name of SupervisorReason for Donation Request:(Required)Include amount requested and specific use of fundsHave you previously received funding from Operation Round Up?(Required) Yes No If yes, list the date(s) and amount(s) of funds received:(Required)Is individual or family receiving any other form of assistance or aid for above stated request? (donations, insurance, etc.)(Required) Yes No If yes, list the source(s) and amount(s):(Required)Name, address, and phone number of individual or organization familiar you’re your situation:(Required)Applicant ConsentI understand that the information contained in this application is for the purpose of obtaining funding from the Ouachita Electric Cooperative Trust on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants that the information provided is true and complete and that the Ouachita Electric Cooperative Trust may consider this statement as continuing to be true and correct until a written notice of change is provided. The Ouachita Electric Cooperative Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements make herein. The undersigned hereby agrees to provide documentation for the expenditure described above of any funds received from the Ouachita Electric Cooperative Trust within 30 days of receipt of the funds. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required)
