Please read the following important information carefully before completing this form:
REASON FOR HARDSHIP REQUEST
I hereby request assistance in accordance with the MLBA Application for Assistance Guidelines. I am an Alorica employee or have attached a written recommendation from my Alorica sponsor and the appropriate documentation 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:
Appropriate documentation includes:
Please note that MLBA guidelines state that more than one grant in any given calendar may not be granted.
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 box, you agree to grant MLBA access to privileged personal information related to this application; including, but not limited to bank records, medical records, etc. You therefore permit MLBA to contact and communicate with third party vendors and other persons/organizations to discuss and attain information related to your hardship claim. This information will be used ONLY in relation to your application and will otherwise be held in full confidentiality by MLBA staff and chapter board members.
Check here if you accept these terms.
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 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.