800-ABC-HACC

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Emergency Assistance Fund Online Application

  * Required field
Student Information  
* First name:  
* Last name:  
* Phone number:  
* Street address:  
* City:  
* State:   * Zip  
* Email:  
HAWKMail email:    

Please select your campus:
 
   
   
   
   
   

For what term are you requesting emergency assistance?
 
   
   
   

 
Please type the year:  
 
Please select what you will be using these funds for (check all that apply):
 
   
   
   
   
   
   
   
   
   
   

If you selected home catastrophe, auto repairs or other, please describe:

 

* Please enter the amount you are requesting:

 
* Please provide a written statement explaining why you are requesting help from the emergency assistance fund:  
 
Vendor information  
* Description of request:  
* Confirm amount of request:  
* Vendor name:  
* Vendor street address:  
* Vendor city:  
* Vendor state:   Vendor zip:  
* Vendor phone:  
Vendor account number (if applicable):  


NOTE: 
Please email a copy of your unofficial HACC transcript, with documentation from the vendor, verifying the amount of the request to: haccscholarships@hacc.edu.  Requests will not be considered without these two documents.

Please check that you have completed the following:
   
   
   
   

By utilizing my electronic signature, I certify that all of the information I have provided is true and correct to the best of my knowledge. I also understand that providing incomplete and/or inaccurate information will result in my request being denied.
* Student first and last name:                 * Date:   mm/dd/yy