Interfaith Screening Application

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

Intake Information

Today's Date (Fecha de hoy)

Preferred Language (idioma preferido)

EnglishSpanishOther

Which program are you applying for? (¿qué programa está solicitando).

How did you hear about us? (¿cómo se enteró de nosotros)

If other, please list (En caso contrario, por favor enumere)

Have you ever resided at our properties or participated in our programs? (¿Alguna vez ha participado en nuestro programa)

Current Living Situation (situación actual de la vida)

Applicant Information

First Name

Last Name

Date of Birth (Fecha de nacimiento)

Social Security Number (número de seguro social)

Phone

Address Line 1

Address Line 2

City

State

Postal Code

County

Race (Carrera)

Relationship Status

Do you have a driver's License or state ID?

Highest level of education COMPLETED (nivel más alto de educación completada):

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 yes, how many children? En caso afirmativo, ¿cuántos niños?

Please list child(ren) name & age:(Por favor, indique el nombre y las edades de los niños):

Co-Applicant Information

First Name

Last Name

Date of Birth (Fecha de nacimiento)

Social Security Number (número de seguro social)

Phone

Race (Carrera)

Relationship Status

Employment Status

Employment History

Employment Status

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?

If yes, how long at current/last employer? (En caso afirmativo, ¿cuánt)o tiempo al final del empleador?

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

Signature (Firma)

****Approval/Denial (IFS Staff ONLY)******

Was an interview scheduled?

YesNo

If no, please select the reason why:

If other, (please explain)

Was the client accepted into the program?

YesNo

If no, please select the reason why:

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