Application Form

Our ProgramsApplication Form

Full Name

Phone Number

Address

Is this address a shelter? YesNo

Names and ages of your children under 18 living with you:

List your valid MINNESOTA DRIVER’S LICENSE number:

Name and address of current employer:

Are you currently receiving government assistance or subsidies: YesNo

List the names of subsidies and amounts of each:

Date you started working with this employer:

Average number of hours worked per week:

Monthly or Biweekly net (take-home) income (monthly or biweekly):
Monthly net amount:

Biweekly Net Amount

Employer or Supervisor contact:
Name

Phone

Are you currently enrolled in school working towards a degree or certificate: YesNo

Name and Address of School:

Degree or program you are working on:

Advisor Name

Advisor Phone:

Advisor email:

Please give a brief explanation of your current situation and why you are in need of a vehicle:

Please list a professional referral that we can call to verify some or all of the above information. We ask that you do not list a relative. Examples: Teacher, Church Leader, Case Worker, Medical Counselor, Business Leader, Social Worker.

Referral name:

Professional position:

Referral phone:

Referral email:

Would you be open to a short interview and a photograph for our website? YesNo