| REQUEST FORM |
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Thank you for making this request on behalf of a community member in need. Please complete the
following form to ensure that we have all the information we need in order to make a timely decision on
your request. Thank you!
NOTE
: Requests cannot be accepted directly from the individual in need. This form must be submitted by a community validator who will represent the person or family for this transaction.
Please
click here
for more details.
Validator Information
Validator Name :
*
Validator Email :
*
Validator Email is Required.
Validators organization or connection to the person in need :
*
Please note: Requests cannot be accepted directly from the individual in need. Requests for assistance have to be made by a community validator who acts on behalf of the person or family in need.
The City or Town Where Person Lives :
*
We prioritize our assistance to people and families in Portsmouth, New Castle,
(Please
click here
for links to other Womenaid groups.)
Has the person been helped by Womenaid in the past 12 months?
*
Yes
No
If YES, please note amount and for what purpose?
*
Name of Person in need : (Strictly confidential and for file only)
*
The exact amount needed :
*
The exact amount requested :
*
Transportation or Vehicle Repairs
NOTE: We recommend having more than one repair estimate
from local businesses, whenever possible.
If possible, please attach a copy of the estimate with this request.
Upload Estimate : (If you have one; otherwise fill in the below Description Box)
*
Max file size: 20MB
Full Description of Repairs Needed. (If Estimate is not Attached to this Request) :
*
Does Garage Guarantee that the Repairs will Result in a Roadworthy Vehicle? (Will pass state inspection)
*
Name of Garage :
*
Name of Contact Person at Garage, if possible :
*
Phone Number for the Garage :
*
Please give us some background information on the situation at hand:
*
The Resources Contacted for Assistance
Please list all the other resources and avenues of assistance that have been contacted relative to this re-
quest. This avoids duplication of services and appropriately places Womenaid of Greater Portsmouth in its correct position of being “the last resort” or “the last piece of the puzzle” in providing assistance. Resources contacted and reasons, if any, for refusal.
Resources Contacted for Assistance :
*
Payment
Vendor To Be Paid :
*
Contact Name for Vendor to be Paid :
*
Phone Number for Vendor Contact :
*
We hope to pay by credit card or by phone.
Email for Vendor Contact :
*
To ensure payments are applied properly, we need to have :
Client name : (Strictly Confidential)
*
Client account number : (Strictly Confidential)
*
Car year/make/model :
*
Or name to reference in the check memo :
*
Where to Send Payment :
Mailing Address for USPS Mailing of a Check:
*
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| REQUEST FORM |
ABOUT US
BOARD MEMBERS
HOW WE WORK
WHAT IS A VALIDATOR?
CHECKLIST
OUT OF AREA REQUESTS
HOW WE HELP
THANK YOU NOTES
HOW YOU CAN HELP
HOST A POP UP
AMAZON SMILE
YOUR TIME
Supporters
DONATE NOW
