Scooter Relief Request Form

To request a grant from the Vespa Club of America Scooter Relief fund please complete the following fields. Required fields are marked with a red asterisk.

PERSONAL INFORMATION

First & Last Name Current Street Address City State Zip Code Email Address Telephone Number

LOSS DESCRIPTION

Please describe the extent of your losses. You do not need to provide a detailed itemized list, rather, give us an idea of whether you are permanently displaced, have lost your home, all your possessions, or whether your losses are more limited.

Loss details

Please describe what the requested funds will be used for. (Replacement of clothing, repair of scooter, temporary housing, transportation, etc…)

Grant use details

GRANT DETAILS

VCOA Scooter Relief will be making assistance grants on a rolling basis. In an effort to make sure we serve all those in need, the first round of grants will be for $200 to $500. Receiving a first round grant does not preclude an applicant from requesting additional assistance in the future.

Amount Requested

If you have asked for scooter parts or scooter repair labor instead of a financial grant, please provide the following information as well:

Scooter Make, Model & Year

Scooter Damage Electrical Paint Body Mechanical

Parts Requested

File Attachment

REFERENCES

If you would like to share any files with us, photos etc. please do so here.

Please provide 2 resources within the local or national scooter community as references.

Reference 1 Name (First & Last) Reference 1 Email Reference 2 Name (First & Last) Reference 2 Email

ADDITIONAL DETAILS