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Application for Services

Please fill in the application to the best of your ability. Incomplete applications can result in a denial of service. If you need assistance filling it out, please contact us at 307-739-4500 to arrange an appointment.

Personal Data Your Name (first, middle, last):

Spouse/Significant Other Name (first, middle, last):

Address:

Physical:
Mailing:
City:	State:	Zip:

Date of Birth (MM/DD/YYYY):		Tax Payer or SSN:		Gender:	MF
Referred to CRC By:

Telephone Numbers & Email Address:

Home:	Work:	Cell:	Messages can be left at:
Email Address:

Marital Status:

Married:

Single:

Divorced:

Living with Partner:

Religion (optional):

Level of Education (optional):

Health Insurance (check all that apply):

Medicaid:

Medicare:

Employer:

Self:

None:

Characteristics (optional, check all that apply):

Veteran:

Student:

Disabled:

Pregnant:

Other:

Monthly Total household Income and Source: Please include all sources of income in your household including yourself, spouse, other family members, roommates, etc. Failure to disclose completely may result in a refusal of services.

Monthly Wages:		Alimony/Child Support:
Social Security:		SSI/SSDI:
Food Stamps:		WIC:
Unemployment:		Other:
Checking Account:	Balance: or N/A
Savings Account:	Balance: or N/A
Bank Name:

Monthly Household Expenses:

Mortgage/Rent:	Gas/Electric:	Phone:
Cable:	Food:	Credit Cards:
Child Support Payments:	Child care:	Car Insurance:
Other Insurance:	Transportation/ Gasoline:	Car Payments:
Other (amount/purpose):

Vehicle(s) Information -Year	Make	Model
Year	Make	Model
Year	Make	Model

Housing & Household:

Housing:

Rent

Own

Homeless

How long have you been in the area?

Landlord or Lender:

Name:

Address:

Phone:

List ALL members of your household including roommates - List name, age, and relationship:

Employment History

Current Employer:		Length of Employment:
Supervisor:		Phone #:		Location:

Past Employers and reasons for leaving:

Spouse or Significant other's Employer:		Length of Employment:
Supervisor:		Phone #:		Location:

References List three references who can attest to your situation - List name, phone number and relationship

Name	Phone Number	Relationship

Other Information

Is your situation medically related?	Yes No	Name of health care provider:
May we contact them?	Yes No	Phone:

what is your specific request from CRC?
What is you plan to get through this situation and what steps have you taken so far?

Please list the members of your extended family

Name	Relationship	Location	Telephone

REQUIRED INFORMATION Check agencies / organizations you are receiving or have received assistance from: Other Agencies:

If monetary assistance is provided, to whom should payment be made? (Checks cannot be written to applicant)

Name Address

By Checking the box below and submitting this application you are agreeing to the following:

I hereby state that the aforementioned is a COMPLETE and ACCURATE representation of my situation and give permission for the Community Resource Center (CRC) to verify the information. I also give permission for the staff of CRC to contact individuals or groups on my behalf, to share my name, circumstances of my situation, and to acquire information as necessary to confirm my situation and seek assistance for me. I give permission for individuals, private or Government agencies to share their knowledge of me and my circumstances. This includes organizations and individuals I may not have listed on my application. This includes any services or assistance they may have given me in the past. I understand that assistance rendered may not be solely monetary and authorize advocay on my behalf.

I understand that a committee makes the decision as to any assistance that I may receive from CRC and CRC intake agents do not have authority to, or capacity of, making immediate assistance available.

I agree to the above statement

Please fill in the sequence of numbers and letters below:

If you have completed the above application to the best of your ability and have reviewed it for accuracy, click the submit button below to send a copy of the application to CRC. Note: if you provided an email address above a copy will be sent to you as well.