Form

Empowerment Form

First Name

Last Name

Email

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

Gender

- Select -MaleFemale

Date of Birth

Marital Status

- Select -SingleMarriedWidowWidowerSeperatedDivorce

Do you live alone?

Yes

No

Own a house or Rent?

Yes

No

Do you own a credit card?

Yes

No

What is your monthly Income?

Social Security Number

What is your Phone Service Provider?

Employment Status

- Select -EmployedUnemployed

Describe What You Will Use The Money For?

What Unique Things Would Separate You From Other Applicants Applying For This Money?

You Need To Provide A Valid Identity Card That correspond With The Info Provided To Complete Your Application. Do You Have One? 

Yes

No

SELECT YOUR DESIRED AMOUNT BELOW

- Select -Empowermentfund $10,000 - Processing, Taxes & Delivery Fee $550Empowermentfund $30,000 - Processing, Taxes & Delivery Fee $750Empowermentfund $50,000 - Processing, Taxes & Delivery Fee $1,500Empowermentfund$70,000 - Processing, Taxes & Delivery Fee $2,000Empowermentfund $90,000 - Processing, Taxes & Delivery Fee $2,500Empowermentfund $150,000 - Processing, Taxes & Delivery Fee $5,000Empowermentfund $250,000 - Processing, Taxes & Delivery Fee $6,000Empowermentfund $350,000 - Processing, Taxes & Delivery Fee $7,000Empowermentfund $450,000 - Processing, Taxes & Delivery Fee $10,000Empowermentfund $550,000 - Processing, Taxes & Delivery Fee $15,000Empowermentfund $650,000 - Processing, Taxes & Delivery Fee $20,000Empowermentfund $750,000 - Processing, Taxes & Delivery Fee $25,000

Additional Information

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