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Application for Assistance
Your Name
First Name *
Last Name *
AKA
DOB
Email
Phone
DL/ID #
Would you prefer text, call, or e-mail?
What is your current housing situation?
Apartment/House
Friends/Family
Motel
Vehicle
Tent
Other
Current Location
What kind of assistance are you requesting?
Emergency Shelter
Interim Housing
Safety from Domestic Violence
Sober Living Assistance
What has led you to reach out for assistance?
Are you a veteran?
Yes
No
Do you have valid identification?
Valid Driver's License
Passport
Social Security Card
Birth Certifcate
No Valid ID
Do you have a criminal record? If yes, please explain.
Two References that can attest to your current situation:
Reference 1:
First Name *
Last Name *
Relationship to Reference:
Reference Phone Number:
Reference E-mail:
Reference 2:
First Name *
Last Name *
Relationship to Reference:
Reference Phone Number:
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Reference E-mail:
Are you employed?
Yes
No
If so, where?
Employer Phone Number:
Please list the job history of all adult applicants for the last 5 years:
Are you a student?
Yes
No
If so, where?
School Phone Number:
Do you have a vehicle?
Yes
No
Do you have a car payment?
Yes
No
How many adults are in your household? (PLEASE NOTE: Each adult must fill out an application.)
How many children are in your household?
Names and Ages:
Anything else you would like to share with us?
How did you hear about A-CROSS?
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