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To apply for assistance please fill in the following form and send back to us.
CONFIDENTIAL GAMEKEEPERS WELFARE TRUST APPLICATION FOR ASSISTANCE 1. PARTICULARS OF APPLICANT Surname First names Date of birth Marital status Spouse/Partner if applicable Surname First names Date of Birth Full address Telephone number 2. EMPLOYMENT HISTORY | Name of employer | Address | Date | Position held | | | | | | | | | | | | | | | | | | | | | 3. BENEFITS RECEIVED Income Support c Disability–related benefits – specify c ……DISABILITY LIVING ALLOWANCE – CAR & TAX PROVIDED…………………………. Any other benefits: | Contributions | £ per month | | (please include benefits below) | | | | | | | | | Pension | | | | | | | £ | | | | | | | | | | | | | | TOTAL | | FEES/OUTGOINGS 5. ASSISTANCE REQUESTED | Nature of assistance requested (please give as much detail as possible including any estimates, also provide any relevant documents available to support your application) | | | 5 ASSISTANCE FROM OTHER FUNDS | OTHER FUNDS APPROACHED (local, national, occupational, Service, etc) with amounts promised if known. | | | 1 | | | 2 | 4 | 6 CERTIFICATE (to be signed by applicant or by a suitable representative) I certify to the best of my knowledge that the information supplied above is correct and that I understand that any incorrect statement may be regarded as an endeavour to obtain help by deception. Signature of applicant ……On behalf ………………………………… Date………… Please return to Mrs H Benson Gamekeepers Welfare Trust Keepers Cottage Tanfield Lodge West Tanfield Ripon HG4 5LE Tel: 01677 470180. E mail:
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Application for Assistance Form 
