Before we can proceed with any application for assistance, we need you to answer the following questions. You can do this by printing this questionnaire and sending it to us, or click here to ask for a form to be posted to you.
Your full name | ____________________________________________ |
Your date of birth | ____________________________________________ |
Your wife's full name | ____________________________________________ |
Your wife's date of birth | ____________________________________________ |
Your telephone number | ____________________________________________ |
Your Address | ____________________________________________ ____________________________________________ ____________________________________________ |
Town | ____________________________________________ |
County | ____________________________________________ |
Postcode | ____________________________________________ |
Do You still have your / his Seamen's Discharge Books? | Yes / No |
Length of your / your husband's Sea Service | ___________________ |
Were you / he Medically Discharged? | Yes / No |
If Medically Discharged, Have You Corroboration? | Yes / No |
i.e. Did You / He Go Before The MN Medical Board and Receive Their Official Certificate? | |
Date of your / his last voyage |
___________________ |
What is your / your wife's current Department for Work and Pensions Benefit called and how much is it? | |
i.e. Retirement Pension, Pension Credit, or Incapacity Benefit |
Do you / your wife have any other income, if so where from and how much is it? |
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including regular grants from any other charities | |||||
__________________________________________ | £____________ | ||||
__________________________________________ | £____________ | ||||
Do you / your wife have any savings, if so how much? | £____________ | ||||
Do you / your wife suffer from any ongoing medical ailments? | Yes / No | ||||
Expenditure |
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Your email address | ____________________________________________ |
If you are sending this questionnaire to us, please address it to:
Samantha Raeburn
Grants Manager
Shipwrecked Mariners' Society
1 North Pallant
Chichester
West Sussex
PO19 1TL