Community Assistance Program
For questions contact Bill Jansen at:
bill.jansen@goodwillsew.com
Referral Agent to complete and fax this application to:
(414) 448-1182
Page 1 of 2
revised 7-21-16
(Please print clearly)
Name of Candidate: _________________________________________ Date of Birth: ________________
Candidate Address: ________________________________________________
City, State and Zip: ________________________________________________
Primary Phone: (_________) ________________________________________
Members of candidate’s household:
Name: ______________________________ Relationship: _____________ |
Date of Birth: ______________ |
Name: ______________________________ Relationship: _____________ |
Date of Birth: ______________ |
Name: ______________________________ Relationship: _____________ |
Date of Birth: ______________ |
Name: ______________________________ Relationship: _____________ |
Date of Birth: ______________ |
Verification
Candidate must be 18 years or older. Goodwill requests a copy of your agency’s 501(c)(3) tax exempt form for our files. If your agency is taxable, we request a copy of your informational pamphlet. We reserve the right to refuse applications from any agency that does not provide us with appropriate verification. Also see the guidelines on the bottom of page 2.
Choose the preferred Goodwill store for shopping (from below):___________________
Wisconsin: Bay View • Beaver Dam • Brookfield • Brown Deer • Delavan • Fond du Lac • Franklin • Grafton • Janesville • Kenosha • Menomonee Falls • Milwaukee-East#1on Palmer Street • Milwaukee-East#2 on Oakland Avenue • Milwaukee-North on 91st Street • Mount Pleasant/Racine • New Berlin • Oak Creek • Oconomowoc • Pewaukee • Sheboygan • Waukesha • Wauwatosa • West Allis • West Bend
Illinois: Addison • Arlington Heights-North on Dryden Ave • Arlington Heights-South on Algonquin Rd • Aurora • Bartlett • Batavia •
Bloomingdale • Bolingbrook • Carol Stream • Carpentersville • Chicago (West Loop) • Des Plaines • Downers Grove • Elmhurst • Frankfort • Glendale Heights • Hoffman Estates • Joliet • Lake Zurich • Lemont • Lombard • Montgomery • Mundelein • Naperville • New Lenox • Northbrook • North Riverside • Orland Park • Palatine on Rand Road • Plainfield • Romeoville • Round Lake Beach • Saint Charles • South Elgin • Skokie coming in October 2016 • Westchester • Willowbrook • Woodridge • Yorkville
Page 2 of 2
Please write a summary of why this candidate needs assistance from Goodwill:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Items needed: Clothing______ |
Furniture______ |
Housewares______ |
Referral (please print clearly)
Referral Contact Name: __________________________________________________________________
Referral Agency: ________________________________________________________________________
Street Address: ________________________________________________________________________
City, State and Zip: _____________________________________________________________________
Work Phone: (________) ______________________Cell Phone (optional): (________) _______________
*Referral Contact
E-Mail address: _______________________________________________________________________
*please note: Referral Contact will be notified by e-mail the dollar value of the voucher within ten days from the date this application is received. If you have not heard from Goodwill after a two week time frame, please contact Bill Jansen by email.
Applications are processed based on availability of funding
Guidelines (revised 7-21-16):
Only two (2) applications per agency per month will be considered, due to budget limitations.
This electronic voucher program is intended to assist candidates with an immediate need. If the need persists, the approved candidate may become eligible again to receive a voucher six months later.
Goodwill does not provide assistance with major appliances, baby cribs, car seats, nor any monetary assistance such as rent, mortgage, utilities, or food. Mattresses and box springs are seldom available.
Approved candidates will need to arrange for pick-up of all items selected at the Goodwill store.
Applications are processed in the order that they are received via fax beginning the 1st of each month.
Employees from any referring agency are not eligible to participate in this assistance program.
Before shopping can begin at the Goodwill store, each approved candidate will need to show to a store supervisor a state-issued ID with name and birth date to match against the electronic voucher.
Vouchers are held electronically in the stores for 60 days, after which time they expire.
