Core-Mark Families Foundation - Employee Eligibility Certification

Employee Eligibility Certification

This page should be filled out by the parent/guardian Core-Mark employee.

Employee First Name *

Employee Last Name *

Phone # *

Core-Mark Employee Number *

Core-Mark Office or Division *

Are You Currently Employed at Core-Mark in a Full-Time Capacity and Have You Been so Employed for Two Years? *

Yes

No

Job Title/Function *

Annual Household Income *

Name of Your Dependent Child That You Wish to Have Considered for Educational Funding by the Foundation

Applicant's First Name *

Applicant's Last Name *

Applicant's Age *

Applicant's Email *

Applicant's Address Line 1 *

Applicant's Address Line 2

Applicant's City *

Applicant's State/(add Province) *

Applicant's Zip-Code *

Applicant's Phone *

The applicant is my dependent child as defined:
biological or adopted; Includes the stepchild or grandchild of employee who is the legal guardian. The applicant also depends on me for his/her support.

*

Employee Signature *

The above information is true and correct to the best of my knowledge.
By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.