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705 Broad St. Box 90496
Durham, NC 27705
Phone: (919) 684-5600
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Kiel Program Application Form

To apply to receive donations from the Kiel Program, please complete the Kiel Program Application Form below along with a Certification of Health Care Provider Form*. The Kiel Program Application Form is submitted to your supervisor and payroll representative, and then forwarded to Benefits for processing. The Kiel Program Application Form should be sent to Duke Benefits:

Email: benefits@duke.edu
Fax: 919-681-8774
Mail: 705 Broad Street (Box 90502)
Durham, NC 27705

In order to ensure that submitted forms are processed in time for payroll cutoff schedules, all documents (applications, certifications of health care providers, and donations) will need to be submitted to the Duke Benefits (see above) no later than noon on the cutoff dates listed here. Final approval by Benefits is required.

*See also the Certification of Health Care Provider Forms for employees and/or family members.

Form Name Format
Kiel Program Application Form PDF
Kiel Program Application Form Word
Some Duke HR forms may require you to list your Duke Unique ID.  If you do not know or are unsure of your Duke Unique ID, you can look it up here.
Some forms available on this web site are in Adobe Portable Document Format (PDF).  You will need Adobe Acrobat Reader to view and print these forms.