Our House CDA Application 2022

Are you currently living in a Housing Program? *
Education (All applicants must have a completed a GED Program or have a High School Diploma) *
 High School/GedUniversty/College UndergraduateTrade/Business or Correspondence School
Name and Location of School
Years Attended
Did you Graduate?
Years Completed

Employment History *
 Employer #1Employer #2Employer #3
Employer (Name of Organization)
Address
Job Title/Duties
Address
Phone
Starting Pay/Ending Pay
Dates you were employed:
Reason for Leaving
Demographic Information
 (Demograpic Information has no impact on program admittance or program status)
Gender
Primary Language
Refugee (Y/N)
Immigrant (Y/N)
Race
Health Insurance (Y/N)
Yearly and Annual Income
Where do you typically access health services?
Homeless (Y/N)
References: Please provide names and contact information below for at least three people who are not relatives and able to make statements about your prior work experience (ex: work supervisor, teacher, co-worker, case manager) *
 Reference #1Reference #2Reference #2
Name
Occupation
Address
Relationship (how do you know this person)
Phone Number
Email Address
Years you have known them

Technology *
 Yes/No
Do you have access to the internet?
Do you have access to computer?
Do you feel comfortable using Microsoft Word with out assistance?
Do you feel comfortable using the internet to do research?
Please sign *
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