Kiel Program Application Form
To request a donation from the Kiel Program, just complete a Recipient Application (PDF), along with a Certification of Health Care Provider Form*. The Recipient Form is submitted your supervisor for documentation and forwarded to Benefits for processing. The Kiel Program Application Form should be sent to Duke Benefits at 705 Broad Street (Box 90502), Durham, NC 27705 (fax number 919-681-8774).
In order to ensure that submitted application and donation forms get processed in time for payroll cutoff schedules all documents (applications, certifications of health care providers, and donations) will need to be submitted to the Benefits Department (fax 919-681-8774) no later than noon on the cutoff dates listed here.
*See also the Certification of Health Care Provider Forms for employees and/or family members.
| Form Name | Format |
|---|---|
| Kiel Program Application Form | |
| Kiel Program Application Form | Word |