Name *

First Name

Last Name

Phone *

(###)

###

####

Birth Date *

MM

DD

YYYY

Marital Status

Single

Married/ Partnered

Qualifications *

Live/Work in MV

Children in MV School

Live/Work in PA

Children in PA School

Disability

Senior Citizen

Veteran

Expiration Date of Driver's License / State ID *

MM

DD

YYYY

Do you have an ADA placard? *

Yes

No

Are you on probation or parole? *

Yes

No

Any restrictions on where you can live? *

Yes

No

What kind of vehicle do you live in? *

Only applicants with a working vehicle that are currently unhoused and living in their vehicle qualify for this program.

Car

Van

RV

Motorhome

Trailer

Other

Is your Residential Vehicle operational? *

Yes

No

Vehicle Registration Expiration Date

Current Vehicle Registration is required

MM

DD

YYYY

Vehicle Insurance Expiration Date

Current Vehicle Insurance is required

MM

DD

YYYY

Do you have a second vehicle? *

Vehicle must be operational. Not all lots have spaces for second vehicles

Yes

No

If you have a second vehicle, what kind of vehicle is it?

Car

Van

Truck

NO SECOND VEHICLE

Only persons registered in the program will be on the lot or in my vehicle *

Enrollment in the program requires this agreement

Agree

I agree to park any second car, commuter car, or tow vehicle on the street a minimum of 500 feet from the lot entrance *

Enrollment in the program requires this agreement

Agree

I will work with a Case Manager to search for permanent housing *

Enrollment in the program requires this agreement

Agree