Crisis Response PRG: Universal Gas Cards

1
STOP! DID YOU FILL OUT THE CLIENT INTAKE FORM ?* This field is required.Before requesting services you must fill out the client intake form or your application WILL NOT be processed. If you have not already done so , please copy and paste this link into your browser and return to this application once complete. Link: https://form.jotform.com/Ark_Refuge/client-evaluation-form
Yes
No
2
Application Submission Month* This field is required. This application is a ONE-TIME benefit on an ANNUAL basis. Please select from the drop-down list below the month you are submitting this application. Previous recipients must wait 12 months before re-applying
Please Select
Please Select
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
3
Referral Source* This field is required.
Please Select
Please Select
1. Friend/Relative
2. Oakland Elizabeth House
3. Report A Victim (Website Form)
4. Heritage Hospital - Sacramento
5. Street Outreach Team ( Foot Canvass)
6. Called Crisis Hotline (+1-866-676-0070)
4
Which Category Best Describes You* This field is required.If none, your are not eligible to receive these services.
Victim of a Crime
Housed DV Victim- Single Adult
Housed DV Victim- Family
DV Victim Homeless with a Family
DV Victim - Homeless withOUT a Family
Elder Abuse ( Over age of 60)
None of the above
5
Name* This field is required.Full Name of Applicant
First Name
Last Name
6
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
7
Contact Number* This field is required.A working phone number where you can be reached.
8
E-mail * This field is required.This is the email we will send all electronic gift cards and correspondence.
example@example.com
9
Household Size* This field is required.How Many people are in your household, spouse and dependents included.
10
Why does client need clothing voucher?* This field is required.Please explain the current emergency (DV/Crime) that prompted your necessity for a clothing voucher.
11
Clothing Voucher Recipients * This field is required.Select 1 from the drop-down list below if you are NOT receiving a hotel voucher and need a Universal Gas Gift Card. Must select only one form of benefit. An applicant can either select Hotel uber or Gas card NOT BOTH.
12
Method of Gift Card Delivery* This field is required.
Please Select
Please Select
In-Person (Physical Card)
Mailed via USPS (Physical Card)
Email on Application (Electronic Card)
13
ADDITIONAL COMMENTS/ NOTES
Should be Empty: