Hope Gospel Mission

Financial Assistance Request Form

Student Information
Name of student
Address
City	State	Zip
Phone	E-mail

Class Information
Name of Class	Total Amount of Assistance Required $

Employment Information
Current Employer	Start Date
Job Title	Supervisor's Name
Employer's Phone Number	Current Wage $
Please explain your need for financial assistance

Additional Information
What is your annual household income?
How many people live in your household?
Have you taken any other classes at Solomon Learning Center?	Yes No
Do you plan to take more classes at Solomon Learning Center?	Yes No
Are you planning to complete a certificate program?	Yes No
If yes, which one?
Are you a resident at Hope Gospel Mission?	Yes No
Have you been in the past?	Yes No
Have you graduated from a Hope Gospel Mission program?	Yes No

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