Application Form

Before you complete the following application, please note:

• Please note:  For your application to qualify, you must answer all questions and complete all parts of the application. 
• Do you have your permanent residence in the Minneapolis/St Paul, Minnesota area? This program is limited to single moms living within the 7-county Metro area (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott and Washington counties) for at least 1 year. Please be prepared to include the name and contact information for your landlord/s for the past year, and the length of residency at each place. 
• Can you afford the repairs, routine maintenance and insurance of a vehicle? This program is restricted to single moms who are employed full-time, and have worked at their current place of employment in the Twin Cities area at least 6 months. Please include accurate contact information for your employer. 
• You must have a current State of Minnesota driver's license. Please have it at hand, and list the numbers accurately. 
• Please be aware that by completing this application, you are providing Newgate School your consent for the release of information for verification purposes.
• We have very few cars available, and many applicants. If you are not selected at the time of your application, please wait 6 months before applying again. 

Full Name

Phone Number

Email

Address

Is this address a shelter? YesNo

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

Name and address of current employer:

Are you currently receiving government assistance or subsidies: YesNo

List the names of subsidies and amounts of each:

List your valid MINNESOTA DRIVER’S LICENSE number:

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

Email

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.

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

Submit