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Application for Vaterans

Re-Entry Program


Thank you for completing the Great initiative enrollment application. Someone from our teem will contact you shortly to discuss the next steps once you have submitted your information. If you have any questions, feel free to call us at (813) 446-0176 Thanks and have a great day

Section 1: Veteran Information

Prefix
Suffix
Client Gender
Birthday
Month
Day
Year
Multi-line address
Client Gender
Race
Marital Status

Section 2: Military Service History

Branch of Service:
Discharge Status:
Dates of Service: From
Month
Day
Year
Dates of Service: To
Month
Day
Year
Combat Veteran?
Yes
No

Section 3: Housing & Financial Status

Current Living Situation:
Literal Homelessness (Street, Car, Shelter)
Imminent Risk of Losing Housing
Couch Surfing / Staying with Friends
Total Monthly Household Income:
$
Source of Income (Check all that apply):

Section 4: Supportive Services Needed

Which areas do you need assistance with? (Check all that apply):

Section 5: Incarceration History

Do you have an incarceration history?
Yes
No
Referred by State Attorney's Office?
Yes
No
Date of Most Recent Incarceration
Month
Day
Year
Offenses Resulting in Most Recent Arrest:
Last Offense Category
Date of Most Recent Release from Prison/Jail
Month
Day
Year
Is candidate required to attend this program?
Is candidate currently on community control?

Section 6: Acknowledgement & Signature

I certify that the information provided on this intake form is true and accurate to the best of my knowledge. I understand that completing this form does not guarantee immediate placement into the program.

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Date
Month
Day
Year
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