Our House CDA Application 2024

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 a 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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