Family Self Sufficiency Program Application

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* Application Date

Application Date

Date

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* Applicant Information

Name *

Social Security Number *

Date of Birth *

Address *

Zip Code *

Phone Number *

Cell Number

Email Address

Education (Highest Level Complete) *

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* How did you hear about the FSS Program

Mailing

AMHA Event

Service Coordinator

AMHA Recertification Appointment

Another Agency

Friend/ Family

Other (if referred by friend/family, include their name)

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* Are you Currently Employed?

Yes

How many hours per week?

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* Do you have any interest or needs related to the following topics? (Check all that apply)

Employment

Job Training

Education

Managing Money/ Budgeting

Utility Assistance

Food

Childcare

Homeownership Preparation

Other (please specify)

Family Self Sufficiency Program Application

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* Application Date

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* Applicant Information

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* How did you hear about the FSS Program

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* Are you Currently Employed?

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* Do you have any interest or needs related to the following topics? (Check all that apply)

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* What are two or three of the biggest problems your family is facing right now?

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* What changes do you want to see in your life?

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* Name three of our personal Strengths

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* Please Include any additional information that you would like to share.