Empowering Destinations

empowring-destinations

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Please apply here for the vehicle giveaway. Your application is held in strict confidence and your information is not shared with anyone. Incomplete applications will not be considered. Your Driver’s License number and date of birth is mandatory.
Take time to tell us your story and how this vehicle will help empower you to reach you goals. What makes you and your situation stand out from other families that are in need, how will the vehicle make a difference in your life. Your story is important in choosing the family in need.

Emails and letters will not qualify as an application. The information on the application is instrumental in choosing the right family in need. We respond to every application to verify that we did receive it.
Empowering Destinations is our way of giving a hand up to a family in need. We are simply a group of small businesses that are pooling our resources and creating a means for a family needing a hand up to sustain their job and shoulder responsibilities. The name “Empowering Destinations” comes from our passion to empower a family in need. Do you qualify?  (Full time employment, no felonies, DUI, DWI, or family violence records.)If you qualify please submit your application. 

Next Vehicle Give Away is May 2014 

First Name* Last Name*
Address* City* State* zip*
Home Phone* Cell Phone* Driver's License Number* Date of Birth*
Email* SS#*

Background Information

Have you ever been denied a driver’s license?*  Yes No
Do you have pending charge or past DUI/DWI?*  Yes No
Driver’s license been revoked or suspended?*  Yes No
Do you have any pending charges, or past convictions for controlled substances?*  Yes No
Have you ever been refused liability insurance?*  Yes No
Have you ever been convicted of a felony?*  Yes No

Any answer that is a yes please explain.

 
 
Have you filed state and federal taxes for the Past 5 years? (if no please explain)*  Yes No
 
Do all members in your family receive a Permanent Fund Dividend? (If no please explain)*  Yes No
 
What is the number of people in your immediate family?*
What is your total annual income? $
Do you pay child support?*  Yes No
Do you receive any other income other than your employment? Please include all family members living your household receiving income.* $
Do you rent or own your home?*
What is your monthly rent or payments?* $
Can you perform the expected duties of owning a vehicle?*  Yes No

Employer #1

Company
Date Start
Date End
Reason for leaving

Employer #2

Company
Date Start
Date End
Reason for leaving

Employer #3

Company
Date Start
Date End
Reason for leaving

Please provide 3 personal references:

Full Name* Phone Number*

Please provide a brief summary of why you believe that you should be chosen to receive the vehicle. Your story helps us determine the importance of choosing you as the recipient. Please explain how this vehicle will help you shoulder your responsibilities.

Consent:
I certify that I have read and understand all of this application.

It is agreed and understood that Empowering Destination's (at times to be referred to as "The Program") or any agents representing Empowering Destinations may investigate my background to ascertain any and all information in concern to my history, whether some is on record or not. I also release employers and other persons named herein from all liability for any damages incurred on account of furnishing such information.

I also understand that the vehicle is for my family in helping us with our transportation needs and that this vehicle is not intended to be sold for monetary value. It is my sole responsibility to maintain the vehicle and that no warranty accompanies the vehicle. The vehicle license will be transferred in my name and at that time will release all agents of Empowering Destinations of any responsibility in regards to the vehicle.

I hereby consent to being the subject of photographs and other media, for the benefit of the Program, to be used in public and to benefit the program.

I hereby acknowledge that, apart from that which was stated in the Program, there were no other promises made and I am solely responsible for all tax liability.

Name*:
Date*:
Security Image*: captcha

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