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ACCELERATE Application Form
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
First Name
*
Your answer
Middle Name
*
Your answer
Last Name
*
Your answer
Street Address
*
Your answer
Street Address Line 2
*
Your answer
City
*
Your answer
State / Province
*
Your answer
Postal / Zip Code
*
Your answer
Country
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Prefer not to say
Primary spoken language
*
Your answer
What is your annual household income?
*
Less than $10,000.
$10,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$50,000 - $60,000
$60,000 - $70,000
$80,000 - $100,000
Please check the following boxes that best describes your living situation
*
One family household( living by myself or with spouse and children only)
Multi-family household (roommates, friends, or relatives other than spouse and children also live in the house)
Shelter or temporary housing (If so, please explain below)
Required
Briefly explain the reason for living in a Shelter or in temporary housing.
Your answer
Do you have any children under the age 18?
*
Yes
No
Explain your living arrangement or household, if needed
Your answer
How did you hear about the program?
*
Word of Mouth
Friend or Family Member
Website
Partner Agency
Community Event
Email
Facebook
Are you a Veteran?
*
Yes
No
Do you have a computer at home?
*
Yes
No
Do you have access to the internet at home?
*
Yes, I have a reliable internet connection at home
No, I do not have a reliable internet connection at home
Do you receive any of the benefits listed below? (check all that apply)
SNAP
SSI
Federal housing assistance (i.e. Housing Choice Voucher, Section 8, live in public housing)
Medicaid
Please list any health benefits you currently receive.
Your answer
Are you currently employed?
*
Yes
No
If employed is it a full time or part time position?
Part Time
Full Time
Clear selection
If employed are you at risk of potentially losing your job?
*
Yes
No
Employer's name
*
Your answer
Job Title
*
Your answer
Employer's Phone Number
*
Your answer
Hire Date
*
MM
/
DD
/
YYYY
Exit Date (If Current put today's date)
*
MM
/
DD
/
YYYY
Reason for leaving
Your answer
Previous Employer (2)
*
Your answer
Job Title
*
Your answer
Phone Number
*
Your answer
Reason for leaving
*
Your answer
Previous Employment (3)
*
Your answer
Job Title
*
Your answer
Phone Number
*
Your answer
Reason for leaving
*
Your answer
Education Level
*
Less than high school
High school diploma or GED
Some colllege
Associate's Degree
Bachelor's Degree
Master's degree and beyond
If you attended College, what was your major and/or degree?
Your answer
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