Introductory Questionnaire Sheet for Graphics

Introductory Questionnaire Sheet – Temporary Assistance Program
Try to answer as many relevant questions on this sheet and send it back. With the answers to these questions, we should be able to get a good start on how we can help assist you with your current needs, and if you qualify for our assistance program. Answer honestly, this is our policy. If it is found later that any of this information was false, or information withheld, you could be disqualified from receiving our services. Please note it could take up to 7 business days to process your request.
Proposed Start Date

MonthDayYear
DateHourMinutesAM/PM Option
- Applicant
  
  Person needing assistance
- Your Name*
  
  First NameLast Name
- Phone Number:*
  
  Area CodePhone Number
- E-mail
  example@example.com
- Address/Previous Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Other contact information ( If you dont have an addrress then list homeless in the box bellow):
- Other contact information ( Please list the number of other persons living with you or in your household):*
- SingleMarriedDivorcedVeteran
- Information
  
  How can we assist you
- Breifly describe your specific need(s) right now:*
- Have you requested services here before:*
- Dates:*
- How did you hear about our services:*
- Were you ever denied services:
- What other channels have you sought assistance:*
- Type of resources
  
  What type of resources do you have right now?
- A JobDisabilityRetirementVA benifitsFamily supportNone
- Give a description:
- A PhoneValid IDTransportationMedical conditionsMedications
- Give a brief description:
- Personal References:
  
  Please list two contacts of people not living with you that we may contact if nessicary:
- Primary Contact Name:*
  
  First NameLast Name
- Contact Phone:*
  
  Area CodePhone Number
- Contact Email Address:
  example@example.com
- Secondary Contact Name:*
  
  First NameLast Name
- Contact Phone:
  
  Area CodePhone Number
- Contact Email Address:
  example@example.com
- Other contact information:
- Background check
  
  This does not automatically disqualify you from services. Please answer honestly.
- Criminal historyHistory of or been involved in Domestic ViolenceN/A
- Brief Description of offense/situation:
- I hereby authorize Arise Church of Canton to release, either verbally or in writing, any and all information, records, or documents pertaining to me to any individuals, organizations, or entities involved in giving programs or charitable work and former or present landlords and employers, and criminal record check. Any person releasing said records is authorized to discuss those reports with such parties.Furthermore, Arise Church of Canton is expressly authorized to obtain my records currently on file with any living program or charitable organization and to retain such information in its database. Any information obtained may be used to grant or deny any request made for assistance. :*
  
  YesNo
- Signature
  
  Clear
- By submitting this form, I acknowledge and hereby certify that all the information provided on this application and information provided verbally is correct and true. I also acknowledge that any information given that is found to be false may disqualify me from consideration.
- CAPTCHA*
- Should be Empty:

Introductory Questionnaire Sheet – Temporary Assistance Program

Applicant

Information

Type of resources

Personal References:

Background check

By submitting this form, I acknowledge and hereby certify that all the information provided on this application and information provided verbally is correct and true. I also acknowledge that any information given that is found to be false may disqualify me from consideration.