Operation Round-Up Assistance Application Form | Mountain Parks Electric, Inc

Personal Information

Name on your MPE electric bill

Spouse's Name

MPE account number

Physical Address

Mailing Address

Home Phone

Work Phone

Please list names and ages of children or other dependents in your home:

Donation Request

Amount Requested (You must include total amount)

Donation to be used for (show each amount and to whom it will be paid or copies of billings)

If you have digital copies of your bills, please upload them here.

This link will allow you to upload or drag and drop files
Maximum 7 files.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Were you referred to us? If yes, please list their name or names

Present Employment Information (must be completed)

What is your current employment status?

Employed

Self-Employed

Unemployed

Retired

None of the above

Other…

Please name your employer(s):

What is your monthly income?

Do you currently have health insurance?

yes

select yes if yes answer

no

select no for no answer

Personal Information

Donation Request

Present Employment Information (must be completed)

Spouse Employment Information

Mountain Parks Electric, Inc.

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