Operation Round Up Individual/Family Application


Please complete the form and submit by clicking on the "Submit Form" button below.

Please note the following: Operation Round Up funds cannot be used to pay for electric bills. Applicants that are awarded funds will be required to have their photo taken when donations are made.

Please attach a cover letter explaining, in as much detail as possible, how these monies will be used and, if a specific amount is needed, what that amount is, with the document upload tool at the end of the form. Detailed application instructions and requirements can be found on the website at www.medinaec.org/oru.

Fields with * are required fields.

Contact Information
*Name (First and Last):
Name of Spouse (First and Last):
*Email Address:
*Daytime Phone (include area code):
Service Address
*Address:
*City:
*State:
*Zip Code:
Mailing Address
Address:
City:
State:
Zip Code:
Please list children or other members that are living permanently in the household. Please include name, age, and relationship to applicant.:
Employment Information
Name of Applicant's Employer:
Address:
City:
State:
Zip Code:
Supervisor's Name:
Supervisor's Phone Number:
Name of Spouse's Employer:
Address:
City:
State:
Zip Code:
Supervisor's Name:
Supervisor's Phone Number:

Have you previously received funds from any other organizations?
*Funding from other organizations?:
If yes, please list the source of funding, the amount and date you received the funds.:

Is the individual or family currently receiving any other form of assistance or aid for the stated request (donations, insurance, etc.)?
*Any other assistance for request?:
If "yes", provide details on the other form(s) of assistance or aid received.:

Is the applicant an immediate family member of a Medina EC Employee?
*Immediate Family Member?:
If "yes", please list the name(s) of the employee(s) and the relationship to the applicant.:

List the name and phone number of individuals/organizations that are familiar with your situation:

Documentation Upload
Please include a cover letter explaining in as much detail as possible, how these monies will be used and, if a specific amount is needed, what the amount is:
*Cover Letter:
The information contained in this statement is for the purpose of obtaining funding from the Medina Electric Cooperative, Inc. Trust on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that the Medina Electric Cooperative, Inc. Trust may consider this statement as continuing to be true and correct until written notice of a change is provided. The Medina Electric Cooperative, Inc. Trust is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein.

Click here to draw your signature.
Signature of Applicant
With your mouse, draw your signature. Then click Finish.


*Name:
*Date:

Click here to draw your signature.
Signature of Spouse
With your mouse, draw your signature. Then click Finish.


Name:
Date: