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Necessitous Circumstance Application

Masonic Fund of Benevolence

Confidential Application for Necessitous Circumstances Assistance

For assistance completing the form, or for clarification / support, please contact UGLQ Membership on: 07 32293533 during normal business hours. If after hours: Contact John Woodford on Mobile No: 0424 144 687MFOB Pty Ltd. Email: enquiries@mfob.com.au

Applicant Details

Applicant Name

Date of birth

Mobile

Landline

Address

When is the best time and what is the best method to contact you ?

Spouse / Partner Details

Mobile (Spouse)

Landline (Spouse)

Spouse Email

Spouse Address

Dependent Details

Name

Relationship

Age

Name

Relationship

Age

Name

Relationship

Age

Charge in Circumstances

Please detail what has happened to cause you to submit this Necessitous Circumstances application.

Verification Details

1. Are you a Queensland Freemason ? If not, go to question 2.

Yes No

Lodge Name

Lodge #

Do you give permission for MFOB to contact the Lodge contact below

Yes No

Lodge Contact person name

Contact Details

2. Are you a member of another Masonic Order ? If not, go to question 3.

Yes No

Please provide details :-

3. Do you have a UGLQ Masonic Connection ? e.g. Father , Brother, Uncle is a Mason.

Yes No

Please provide details:

4. Do you give permission for MFOB Pty Ltd to share your share your information with with a third party? For example, Uniting Care Queensland, Hand Heart Pocket (HHP) etc.

Consent:

Yes No

Please provide your bank details :

Bank Name

Account Name

BSB

Account Number

I acknowledge that I have read and understand the Masonic Fund of Benevolence Privacy Statement

Applicant Name

Signature

Submission Date

311 Ann Street Brisbane 4000

enquiries@mfob.com.au

07 3229 3533

Who we are

The Masonic Fund of Benevolence (MFOB) is an organisation dedicated to provide benevolence assistance to Queensland Freemasons and their dependant immediate family members, in Necessitous Circumstances or help them with Disaster Relief who meet residency tests and ordinarily reside in Queensland. These programs are not provided to the public.