Apply for Assistance : What We Do : ACROSS

Your Name

First Name *

Last Name *

AKA

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DOB

Email

Phone

DL/ID #

Would you prefer text, call, or e-mail?

What is your current housing situation?

Apartment/House
Friends/Family
Motel
Vehicle
Tent
Other

Current Location

What kind of assistance are you requesting?

Emergency Shelter
Interim Housing
Safety from Domestic Violence
Sober Living Assistance

What has led you to reach out for assistance?

Are you a veteran?

Yes
No

Do you have valid identification?

Valid Driver's License
Passport
Social Security Card
Birth Certifcate
No Valid ID

Do you have a criminal record? If yes, please explain.

Reference 1:

First Name *

Last Name *

Relationship to Reference:

Reference Phone Number:

Reference E-mail:

Reference 2:

First Name *

Last Name *

Relationship to Reference:

Reference Phone Number:

Reference E-mail:

Are you employed?

Yes
No

If so, where?

Employer Phone Number:

Please list the job history of all adult applicants for the last 5 years:

Are you a student?

Yes
No

If so, where?

School Phone Number:

Do you have a vehicle?

Yes
No

Do you have a car payment?

Yes
No

How many adults are in your household? (PLEASE NOTE: Each adult must fill out an application.)

How many children are in your household?

Names and Ages:

Anything else you would like to share with us?

How did you hear about A-CROSS?

Apply for Assistance

Application for Assistance

Two References that can attest to your current situation: