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Navigation Menu
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HOME
News & Blog
Privacy Policy
MATS Can Help
MATS FAQ
Application Form
Resources
About Homelessness
About MATS
Newsletter
The People We Serve
Success Stories
MATS Board of Directors
Annual Reports
Donate
Donate to MATS
Hope Fund
The Steven Fund for Kids
Fundraising
Contact
Employment/Volunteer
Application Form
When you meet our program manager you will need to bring:
Proof of COVID-19 vaccinations (Policy under FAQ segment)
Application Form
PDF printable or you can
scroll down
to fill out the online form below
Background Check
(to be completed at a later date)
Financial Information Form
Verification of income, pay stub
Bank statement
NH DHHS Eligibility of Benefits Letter (if you have one)
Please enable JavaScript in your browser to complete this 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
Single
Married
Widowed
Divorced
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
Sexual Offenses
Parole/Probation
Child Support
Child Custody
Divorce
DCYF
Criminal Charges
Assault Charge
Other charges
Traffic tickets
DUI
Parking tickets
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
References for housing
Employment
Transportation
Money management /budgeting/credit report
Applying for assistance
Completing / filling out applications
Child care
Time management
Housekeeping
Health care services
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
Website
Submit