Emergency Fund – Harvest Restaurants

Please answer the following questions and do so providing information and feedback within the “Comments:” section at the end of this form for your Managers and Chefs.

** ALL INFORMATION ENTERED WILL BE STRICTLY CONFIDENTIAL **

Name (must match name on paycheck):

Restaurant:(Required)

Length of Employment:(Required)

Average Weekly Hours Worked:(Required)

Loan or Gift Amount (max request of $1,000.00):(Required)

Payback Amount Per Week (if applicable):(Required)

Please Provide a Detailed Account of What the Loan or Gift Will Be Utilized For:(Required)

Please Attach Any Other Useful Documentation (car estimate, receipts, medical bills, etc.):

Drop files here or

Accepted file types: doc, docx, pdf, txt, gif, jpg, jpeg, png, Max. file size: 15 MB.

Check Made Payable to:(Required)

E-Signature:

Manager Signature:

This field is for validation purposes and should be left unchanged.

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