GNG Application

Date:
Referring Agency Information
Name:
Address:
City:
State:
Zip:
Applicant Information
Name:
SSN:
DOB:
Address:
City:
State:
Zip:
How long at this address:	Years    Months    Own    Rent
Day Phone:
Evening Phone:
Email Address:
Number of adults in household:	Children:
Number of CO licensed drivers:
Name & age of children:
Employment
Are you currently employed:	Yes    Occupation:     No    When do you expect to be employed:
Employer:
Address:
City:
State:
Zip:
Phone:
Date of hire:
Gross pay:	per week
Career Goals
Please describe in detail your current job search activities and/or employment/career goals.
Monthly Income Please list all sources of income for entire household:
Employment ANFC/TANF Unemployment Child Support VA Pension Social Security/Disability Other Income Total Monthly Income
References Please provide us with the names of non-relatives who understand your employment status and need for a vehicle.
Name: Name: Relation: Relation: Phone: Phone: Caseworker: Agency:     Phone:
License
Valid Colorado License:	Yes    No    License Number:
If you do not have a license when will you have one?
Transportation Needs
Do you live on or near a public transportation line? Yes No If yes, explain why you are applying for GNG assistance.
Do you or anyone in your house own a car? Yes No If yes, explain why you are applying for GNG assistance.
How many working vehicles are in your household? Please list:
If you now own a vehicle, explain why you are applying for another vehicle:
Type of transmission you can drive.	Both    Automatic    Standard
Type of vehicles you will accept:	Any    2 Door    4 Door    Van    Truck    Station Wagon
Vehicle Cost Every car donated to Good Neighbor Garage that is designated for qualified participants will be safe to drive after repair. The expenses associated with the repair of the vehicle help to determine the final price of the vehicle. What price would you be able to pay? (We are not able to accept payment plans, nor do we accept trade-ins.)
$801-$1000    $1001-$1200    $1201-$$1500
Program Enrollment Please indicate below if you are currently enrolled in any of the following programs. (Please check all that apply.)
Temporary Assistance to Needy Families (TANF)
Employment Assistance:	Date Enrolled: Caseworker: Phone:
Head Start:	Date Enrolled: Caseworker: Phone:
Community Mental Health Center:	Date Enrolled: Caseworker: Phone:
Transitional Housing:	Date Enrolled: Caseworker: Phone:
Other programs:	Date Enrolled: Caseworker: Phone:
Additional Information
What is the most important reason you need a car?
You are not required to furnish this information, but are encouraged to do so. The answers to these questions are optional and will not affect your eligibility for a car.
Marital Status:	Married    Never Married     Seperated    Divorced    Widowed
Ethnic Background:	Caucasion    African American    Native American    Hispanic    Asian    Other
Education Level:	0-8    9-12 Non-Graduate    HS Graduate/GED    Some College    2-4 Year Graduate
Are you a Veteran?	Yes    No
Disabled:	Yes    No
If so, explain:
Mandatory Release of Information The information contained in this application is accurate to the best of my knowledge. I understand that if I knowingly give false information in this process, my application will be denied. I also understand that to help me get a vehicle from the Good Neighbor Garage, application information may need to be verified by or discussed with another agency, employer, caseworker and/or reference. I give the Good Neighbor Garage permission to do so if necessary.
By clicking "Submit" you are effectively signing this application with your signature.