Nancy's Closet - Mom Warrior Form

1
Date* This field is required.
Date
Month
Day
Year
2
Name* This field is required.
First Name
Last Name
3
Email Address* This field is required.
example@example.com
4
Your Best Phone Number* This field is required.We will call and message you
Area Code
Phone Number
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
How did you learn about us?
Please Select
Please Select
Referral
Online
SMC Group
I'd like more information about joining your team
Other
7
Reason for reaching out (Please select all that apply)* This field is required.
Please Select
Please Select
Hardship
Financial Assistance
Entrepreneurship
Just shopping
I have questions
I'd like more information about joining your team
8
If you marked shopping, what type of products and/or services are you in need of?
Please Select
Please Select
Health
Services
Health Insurance
Financial
Beauty
Self-Care
Fashion and Accessories
Potpourri
Other
9
If you marked hardship, what type(s) are you currently experiencing (check all that apply)?
Please Select
Please Select
Financial
Housing
Marital
Mental Health/Emotional
Other (briefly explain below)
10
For Other, please explain here (from previous question above)
11
Are you currently employed?* This field is required.
Yes
No
Self-Employed
Retired
12
If you are employed, where, how long and what is your title?
13
What is your average monthly income?* This field is required.
$0 - $4,999
$5,000 - $9,999
$10,000 - $14,999
$15,000 and above
14
If you are unemployed or without a current income, please provide a brief explanation as to why and for how long, as well as your future plans for employment.
15
Are you currently in an assisted housing arrangement?
Yes
No
16
If you answered "Yes" to the previous question above, please identify the location
17
Have you ever lived in assisted housing?
Yes
No
18
If you answered "Yes" to the previous question above, please identify the following: the location, dates lived in assisted housing, and the reason for leaving?
19
Do you pay utilities?
Yes
No
20
If you answered "Yes" to the previous question above, what type of utilities and how much are you paying per month for each utility?
21
Do you currently have minor children living with you?
Yes
No
22
If so, please list their names and ages.
23
Do you have custody of Children?
Yes
No
24
If answered yes to the previous question, which ones and what percentage?
25
Are all of your children currently enrolled in full-time school?
Yes
No
26
If not, which one(s)? Briefly list reason why.
27
Are you and/or anyone in your household in an emergency situation and/or in fear of being harmed?
Yes
No
28
Do you own any checking or savings accounts? (Yes/No)
Yes
No
29
What is the total combined balances of all?
30
Do you own, rent, or are you currently living with a friend/family member (check which one applies)?
Please Select
Please Select
Own
Rent
Living with Friend/Family
31
Do you consider yourself to be a social or private person?
32
Are you willing to comply with the advisement provided on behalf of our support staff professionals?
Yes
No
33
1. Name* This field is required.
First Name
Last Name
34
Phone Number* This field is required.
Please enter a valid phone number.
35
Email Address* This field is required.
example@example.com
36
Relationship to you
37
2. Name
First Name
Last Name
38
Phone Number
Please enter a valid phone number.
39
Relationship to you
40
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