Screening Application

Screening Application

PLEASE fill out the form completely. Place “N/A” in any section that does not apply. Incomplete applications will not be given further consideration.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
EnglishSpanishOther
Pre-Program Information / Información del Programa
Which program are you applying for? (¿Qué programa está solicitando?):*
Pick only one program to apply for.
How did you hear about us? (¿Cómo se enteró de nosotros?):*
Have you ever resided at our properties or participated in our programs?(¿Alguna vez ha participado en nuestro programa?):*
Highest level of education COMPLETED (nivel más alto de educación completada):*
Current Living Situation (Situación actual de la vida):*
Are you pregnant? (¿Está embarazada?):*
Do you have children under the age 18 in your legal custody?(¿Tiene niños menores de 18 años bajo su custodia legal?):*
If NO, you do not qualify for the program.
If you chose YES to the question above, how many under the age of 18 children do you have? (Si respondió SÍ a la pregunta anterior, ¿cuántos hijos menores de 18 años tiene?)
Do you have at least 6 consecutive months of rental history in the past 3 years? ¿Tiene al menos 6 meses consecutivos de historia aquiler en los últimos 3 años?*
*Must be able to provide proof of rental history.
Do you have at least 6 consecutive months of employment history in the past 3 years? ¿Tiene al menos 6 meses consecutivos de historia laboral en los últimos 3 años?*
*Must be able to provide proof of employment.

Applicant Information / Información del Solicitante
Date of Birth (Fecha de nacimiento):*

MonthDayYear
Date
Gender (Género): *
Race (Carrera):*
Relationship Status (Estado civil):*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County / Condado:*
Drivers License or State ID # (Licencia de conducir o identificación estatal):*
Matricular, Green Card or Passport # (Número de matrícula, tarjeta verde o pasaporte)
Social Security Number (número de seguro social):*
Primary Applicant Employment Status*
Do you have a Co-Applicant (spouse or partner) who will be applying for the program? (¿Tiene un co-solicitante (cónyuge o pareja) que solicitará participar en el programa?*

- Name
  
  First NameLast Name
- Gender (Género):
- Drivers License or State ID # (Licencia de conducir o identificación estatal):
- Social Security Number (número de seguro social):
- Matricular, Green Card or Passport # (Número de matrícula, tarjeta verde o pasaporte)
- Race (Carrera):
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Co-Applicant Employment Status (Estado laboral del co-solicitante):
- Does the co-applicant have a criminal background? (¿Tiene el cosolicitante antecedentes penales?)
- Does your co-applicant drug or alcohol abuse? (¿Tiene antecedentes de abuso de drogas o alcohol?)
- Has the co-applicant ever been convicted of a sexual offense or do you currently have sexual charges pending? (¿El co-solicitante alguna vez ha sido condenado por un delito sexual o actualmente tiene cargos sexuales pendientes?)

Criminal/Alcohol/Drug History
Do you have a history of drug or alcohol abuse? (¿Tiene antecedentes de abuso de drogas o alcohol?)*
Do you have a criminal background? (¿Tiene antecedentes penales?)*
*We will run a background check before you can be approved for the program.
If YES, what was the charge? (En caso afirmativo, ¿cuál fue el cargo?)
Have you ever been convicted of a sexual offense or do you currently have sexual charges pending? (¿Alguna vez ha sido condenado por un delito sexual o actualmente tiene cargos sexuales pendientes?)*
Do you have a history of mental health or illness? (¿Tienes antecedentes de salud mental o enfermedad?)*
If yes, what was the diagnosis? Does it prevent you from working? (En caso afirmativo, ¿cuál fue el diagnóstico? ¿Te impide trabajar?)
I HEREBY CERTIFY that the information provided in this form is complete, true, and correct to the best of my knowledge.
Applicant Signature*

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Thank you for applying to receive services through Interfaith Family Services. After reviewing your application, we found that you do not currently meet one or more of our minimum eligibility requirements:
- Having children age 18 or younger in your legal custody.
- No drug use within the past 12 months
- At least six consecutive months of rental history in the same residence
- At least nine consecutive months of employment with the same employer within the last three years.
- Legal authorization to work in the United States.
- No felony convictions or violent or sexual offenses.
Although we are unable to offer enrollment in our program at this time, we would like to connect you with other resources that may be better suited to your current needs.

https://www.211texas.org/
Should be Empty:

Screening Application

Pre-Program Information / Información del Programa

Applicant Information / Información del Solicitante

Criminal/Alcohol/Drug History

I HEREBY CERTIFY that the information provided in this form is complete, true, and correct to the best of my knowledge.