Please review the complete "Application for Assistance" form and confirm you have all required information before you start completing online. Thank you.
Today's Date
Name
Nickname
Home Phone
Cell Phone
E-mail
Address
City
State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA RI SC SD TN TX UT VT VA WA WI WV WY
Zip
Name of Residence (if applicable)
Residing In Street Car Halfway House Sober House Shelter Section 8 Subsidized Housing Other
Co./org. providing housing
Contact at Residence
Contact Phone
Spouse Name (optional)
Spouse Contact (optional)
List two people living in any state in the U.S. with whom you always keep in contact, who retain a constant phone number.
Contact 1 Name
Contact 1 Relationship
Contact 1 Phone
Contact 2 Name
Contact 2 Relationship
Contact 2 Phone
Company Name
Company City
Supervisor Contact
Company Phone
Professional - not friends or relatives: Employers, supervisors, present or past co-workers, college professors, case workers, probation officers, etc. are appropriate here.
Reference 1 Name
Reference 1 Business
Reference 1 Relationship
Reference 1 Phone
Reference 2 Name
Reference 2 Business
Reference 2 Relationship
Reference 2 Phone
Check which program fits your needs. You may also apply for the bus card.
Check which program fits your need. You may only apply for one. Tools for the Job Internship Your Own Business
On the Bus Bus card for transportation for first month of employment.
For Internship, Tools For the Job or On The Bus:
Name of Employer
Job Title
Supervisor/Contact Name
Supervisor/Contact Phone
Please bring to meeting list of items needed, costs and place to purchase; may include uniforms. (Max is $500)
Describe type of tools you need:
Name of Profession
Years in Profession
An opportunity for experience in your field of interest. These do not pay a salary but allow the participant to gain job experience and references.
Name of profession(s) in which you would like to gain experience:
Bring a list of start-up expenses to meeting. (Max is $2,000)
Type of Business
Years Experience in this Profession
The following questions will address some personal issues. Answering YES to any of these questions WILL NOT disqualify you from receiving our assistance. Hopefully it will allow is to make you aware of additional resources.
Are any of the following an issue for you? Chemical Abuse Addiction Pending Legal Issues Mental Health Concerns Lack of Needed Medication
Do you have Health Insurance? Yes No
Describe how you are dealing with any of the above issues you checked.
If current, please provide the following information.
Case Manager or P.O. Name
Case Manager or P.O. Phone
County or State
Outstanding warrants and issuing county.
Number of Children 0 1 2 3 4 5 6 7 8 9 10 or more
Number of Dependants 0 1 2 3 4 5 6 7 8 9 10 or more
Marital Status Single Divorced Married
Source of Income MFIP GA SSI MSA
Other Income
Do you have a Food Card [Stamps]? Yes No
If you do not have a Food Card, call 651-209-7963 for information on how to receive them.
List individuals you can rely on for help: (family, friends, co-workers, church or other community members)
Check all forms of transportation you use. Bus Car
Other Transportation
Please explain why you need this assistance.
What personal strengths/coping skills do you have that will help you succeed in this position?
(Examples: Punctual, good heart, caring person, hard worker, dedicate myself to something 100 percent.)
How did you hear about At Home Group?
Please list other ways or places you have tried to get help for the above request.
There is no other place that gives this type of assistance.
These places give assistance but I wasn't approved because.
Are you legally allowed to work in the United States? Yes No
Were You Born in Minnesota Yes No
If not born here, years in Minnesota?
List other states/countries of residence.
Highest education level completed. None Grade School Junior High High School College
Bring work resume to meeting.
I agree to use my support in the manner designated above and agree to respond to follow-up calls from At Home Group tracking my progress to create databases to attract grant financing for future clients.
Agreement I attest that all the information I provided is accurate to the best of my knowledge.
