Lindsey House Application 2.0

Lindsey House Application
Applicant Name:*

First NameMiddle NameLast Name
Please list any alternative names, such as maiden or married names:
Birthdate*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race/Ethnicity (Choose all that apply)

Native American/Alaska NativeWhiteHispanic/LatinoAsianHawaiian/Pacific IslanderBlack/African AmericanOther

Safety
Have you ever been a victim of domestic violence?

YesNo
If so, when was the most recent incident?

Within the last 3 monthsWithin the last 6 monthsWithin the last yearMore than a year ago
Have you received therapeutic services related to the domestic violence?

YesNo
If yes, where did you receive services?
How long did you receive services?

Employment History

This portion of the application must be filled out or an explanation for why there is no work history must be provided. To skip this section will disqualify your application.
Do you have work history?*

YesNo
If you have no work history, please explain.
Current Employer:
Job Title:
Wage/Salary
Start Date
Month and year
Previous Employer:
Job Title:
Wage/Salary
Start Date:
Month and year
End Date:
Month and year
Why did you leave this job?
Previous Employer:
Job Title:
Wage/Salary
Start Date:
Month and year
End Date:
Month and year
Why did you leave this job?

Education
Please select the highest level of education that applies*

8th GradeSome high schoolGEDHigh school diplomaSome collegeCollege degree or higher
What is your last grade completed?
Are you currently attending a college or training program? If so, what are you pursuing and where?
Do you have any active certifications (e.g. CNA, welding, forklift)?

Income, fill in numbers for all that apply. Failure to fill this section out may disqualify your application.*

	Monthly Amount
Employment Wages
TANF
SSI
SSDI
SNAP (food stamps)
Assistance from family/friends
Child support
Other

Monthly expenses, fill in numbers for all that apply. Failure to fill this section out may disqualify your application.*

Debt, give closest estimate of total*

	Total Amount of debt
Credit Cards
Loans (bank or car)
Student Loans
Housing (evictions/utilities)
Back child support
Legal
Medical
All other

Program Participation
Please list at least 2 plans/goals you would like to achieve while at Lindsey House. Planning, budgeting and setting/achieving goals are a significant portion of the Lindsey House program.*
Should be Empty:

Lindsey House Application