Shipwrecked Mariners' Society - Grant Application Form

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?

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
Mortgage/Rent: £____________
Monthly, Council Tax: £____________
Monthly, Water/Sewage Rates: £____________
   
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