Do you need assistance?Sometimes bad things happen to good people. We’re here to help. Contact us. Please fill out the form in its entirety and a representative will be in touch with you soon. Candidate Information Form - Vehicle Repair Date * MM DD YYYY Family/ Person in need * First Name Last Name Please select one: Applicant is a Greene County resident. Applicant is a Putnam County resident. Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email Referring Individual/Organization (If applicable) Phone (###) ### #### Referring NHN Member (If applicable) Phone (###) ### #### If URGENT, describe catastrophic or emergency event. Specific Reason for Request * Please be as detailed as possible about the specific need for a vehicle or vehicle repair AND (if applicable) why you support this candidate's request. Recipient MUST have a valid Georgia driver's license. Will this be the only car in the family? Yes No What has been done already to rectify the problem? * Provide two references for this individual/family * Please provide a full name and phone number for each. Please select all of the boxes below stating that you have read and understand the following: * I understand that basic confirmation of financials will be provided and utilized as appropriate. I understand that a background check may be required when appropriate. I understand that the applicant demonstrates the need for a hand-up and not a hand-out. I understand that a minimum of two reference checks is required. I understand that Neighbors Helping Neighbors does not fund on-going expenses such as utility bills, repairs to rental properties or payments of loans. Applicant has means to obtain insurance. * Yes No Applicant's Vehicle Needs Repairs: Please select one. Vehicle is Running Vehicle is NOT Running What repairs are know to be needed? Please explain in as much detail as possible. What is the vehicle's make and model? What is the vehicle's VIN#? Recipient: By typing your name in the box below, you verify that the information submitted in this application is true and accurate to the best of your knowledge. * Type Full Name Below Referring Party (If applicable): By typing your name in the box below, you verify that the information submitted in this application is true and accurate to the best of your knowledge. Type Full Name Below Your request has been received. A member of our team will be in touch with you soon. Thank you!Neighbors Helping Neighbors
