Transitional Housing Application
Date Eligible to Enter Housing *
MM
/
DD
/
YYYY
Full Name *
Last Known Address *
Phone Number *
E-mail Address
Are You Currently Homeless *
Date of Birth *
MM
/
DD
/
YYYY
Social Security Number
Gender *
Ethnicity *
Race *
Place of Birth *
Highest Education Completed *
Are you currently employed? *
Are you currently incarcerated? *
If so, what is your PID number?
What is your supervisor's name?
Where are you incarcerated?
Are you a veteran? *
Do you have a copy of your DD214?
Clear selection
Are you currently receiving government benefits? *
Required
Marital Status *
Where did you hear about transitional housing with the Lexington Rescue Mission? *
Are you able to live in an open dorm area with up to 14 men, and can you handle sleeping on the top bunk of a bunk bed? *
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