Student Emergency Support Fund Application

Name *

Millikin ID # *

Preferred Phone Number *

Campus Address (number, street, and apt. or suite no., city, state, and ZIP code) *

Permanent Address (number, street, and apt. or suite no., city, state, and ZIP code) *

E-mail *

Year in College *

Amount Requested *

Amount must be between $500 - $3,000.

Which best describes your area of need? *

Please list area of need *

Statement of Need *

Please briefly describe your need for emergency grant assistance, including how the funds will be utilized.

Disbursement of Funds *

I wish to have the emergency funds applied directly to my student account.

I wish to have the emergency funds disbursed directly to me.

Please Select One:

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