Application for Assistance

The Mary L. Peyton Foundation (“Foundation”) was created for charitable and educational purposes in 1937 by Joseph C. Peyton, who founded Peyton Packing Company.  Today the Foundation is an operating non-profit charity, 501(c)(3), chartered by the State of Texas in 1971.  Financial aid and assistance are given by the Foundation to legal residents of El Paso, Texas, who are qualified needy individuals or who are incapacitated and lack sufficient funding for necessities of life, medical attention and equipment, and educational/vocational assistance.  

PLEASE NOTE THAT NO FUNDING WILL TAKE PLACE BETWEEN 24 NOVEMBER 2017 - 17 JANUARY 2018

1. APPLICANT INFORMATION
Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
Please specify how you would like the Foundation to communicate with you.
Please Select One
Date *
Date
Please Select One
$
Employer Address *
Employer Address
Employer Phone *
Employer Phone
Employment Start Date *
Employment Start Date
Employment End Date *
Employment End Date
If currently employed select today's date
If Unemployed, When Was Your Last Employment *
If Unemployed, When Was Your Last Employment
If employed select today's date
If employed put n/a
2. ASSISTANCE REQUESTED FROM FOUNDATION
$
If none put n/a
If none put n/a
If none put n/a
$
3. FINANCES
4. REFERENCES
Please Provide the Name, Address and Phone Number of 2 References Not Related to The Applicant:
Reference 1 Name
Reference 1 Name
Reference 1 Address
Reference 1 Address
Reference 1 Phone *
Reference 1 Phone
Reference 2 Name *
Reference 2 Name
Reference 2 Address *
Reference 2 Address
Reference 2 Phone *
Reference 2 Phone
5. AUTHORIZATION
By Checking the below box the Applicant hereby authorizes the release of the information contained in this Application for Assistance unto the Foundation to evaluate the assistance the Applicant is requesting herein. The Applicant further certifies that the information contained herein is true and correct, and authorizes the Foundation to verify the same. The Applicant hereby agrees that deliberate misrepresentation of any information submitted herein shall automatically subject the Applicant to denial of any assistance requested. THE APPLICANT HEREBY AGREES TO RELEASE AND HOLD HARMLESS THE FOUNDATION, AND ITS DIRECTORS, OFFICERS AND EMPLOYEES FROM AND AGAINST ANY AND ALL LIABILITY, EXPENSE, OR DAMAGE OF ANY KIND OR NATURE AND FROM ANY SUITS, CLAIMS, OR DEMANDS ON ACCOUNT OF ANY MATTER OR THING, WHETHER IN SUIT OR NOT, ARISING OUT OF THE ACTS OR OMISSIONS OF THE FOUNDATION IN CONNECTION WITH THIS APPLICATION.
TERMS AND CONDITIONS *