Application Form

Date *

Name *

First

Last

Maiden or other names used

Mailing Address

City

State

Zip Code

Phone

Phone or email is required

E mail address

COVID-19 Vaccine Dates. * Please see Policy in FAQ section of website *

Marital Status

Are there any current or previous restraining orders or safety concerns

Yes
No

If yes please explain

Have you ever applied or been a guest at MATS before?

Yes
No

If Yes, when

Have you stayed at other shelters

Yes
No

If Yes, when (copy)

Have you applied for assistance through the town welfare

Yes
No

If yes, are they currently or willing to assist you

FINANCES Do you have a bank account

Yes
No

Type

Checking
Savings
Both

Name of bank

Current balance

If no, do you have past due, overdrawn bank accounts and how much is owed

FAMILY Children, family, others who are requesting shelter at MATS. (Please include children who you have visitation with) Name, DOB & Age, Relationship

Do you have physical custody through the courts for the children listed above

Yes
No

School or day care attending

Is anyone in your household currently pregnant

Yes
No

Do you or family members smoke

Yes
No

Do you or family members drink alcohol

Yes
No

TRANSPORTATION Do you have a valid driver’s license

Yes
No

If no, what is the status of your licence

Do you have a vehicle

Yes
No

Make/model/year

Registered

Yes
No

Inspected

Yes
No

Is your vehicle in need of repairs

Yes
No

If no vehicle, how do you get around

HOUSING HISTORY Please list housing for past 5 years. Please tell us what your current living / housing situation is and why you need to move. Current:

Date, Address, Reason For Moving, Rent, Contact name & no

Do you have storage for your belongings

Yes
No

EMPLOYMENT Last five (5) years of employment: (needed on all adults in household) Current Employment:

Dates employed

Pay rate

How often paid

Supervisor

Phone

May we contact to verify employment

Yes
No

Previous employment & address

Dates employed

Pay rate

How often paid

Supervisor

Phone

Reason for leaving

Military Service

Older employment history

EDUCATION Highest level completed

Do you have a copy of your Diploma/GED

Yes
No

Degrees or certifications

Are you currently participating in any type of job placement or training program

Yes
No

LEGAL Do you have a criminal record / history

Yes
No

Have you ever been convicted of a misdemeanor

Yes
No

Have you ever been convicted of a felony

Yes
No

If Yes explain

Do you have any current/pending/past legal matters

If Yes please give date and explain

Do you have/had any current or past use of illegal substances

Yes
No

If Yes please explain

Please add any additional information, comments, or explanations here

I certify that the information contained in the application are true and complete to the best of my knowledge and understand that if accepted as a guest of MATS, falsified statements on this application shall be grounds for removal. I authorize investigation of all statements contained herein and the references, landlords and employers listed above to give you any and all information concerning my previous rentals, employment and any pertinent information they may have, personal or otherwise, and release MATS from all liability for any damages that may result from utilization of such information.

Yes

ASSISTANCE In what areas do you feel you need assistance and/or are obstacles around your housing / employment needs

Other information and or resources you and your family are in need of

What are the barriers you face to obtaining and keeping stable housing and/or employment? How can MATS be of assistance to you in removing these barriers

Any additional information you would like MATS to consider or you would like to add to the application

MEDICAL Name

DOB

Do you have medical insurance for yourself

Yes
No

Family members

Yes
No

Name of physician(s) and phone number(s)

Current medical or physical conditions or food allergies for each family member

Diabetes
Seizure Disorders
Heart Condition

Who

Names of Medications/frequency that you or other family members are currently taking

Have you been diagnosed with any physical or mental disability? If yes, what

In case of medical emergency you give Monadnock Area Transitional Shelter permission to contact the person listed below.

Yes

Medical Emergency Contact Name

Telephone

Relationship

Application Form

When you meet our program manager you will need to bring: