BONNE TERRE MINISTERIAL ALLIANCE
COMMUNITY SERVICES REGISTRATION FORM
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Email *
First Name *
Middle *
Last Name *
Maiden Name
Date of Birth *
MM
/
DD
/
YYYY
Gender at Birth *
Street Address *
Unit #
City *
State *
Zip Code *
Phone Number *
area code + number ..... With no hyphens, periods, commas, or parentheses.
Phone Type
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email
Preferred Contact Method
Employment
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How did you hear about us?
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Household Income Per Year
Total income for all household residents
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Income Sources
List income sources for all household income
Assistance Currently Receiving
Check all that apply
SSI
Food Stamps
LIHEAP
EMAA
United Way
Other
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Other Conditions *
SELECT ALL THAT APPLY
What Are You Needing Assistance WIth? *
Check All That Apply
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Provide a brief description of why your are requesting assistance:
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By signing you consent to have your picture taken and records stored both physically and digitally for an indeterminate amount of time. By signing below you also state that the information above is true and that there has been no attempt to conceal or hide information that might have an impact on the decision made in your case. By signing below you also consent to all checks needed for a decision to be made in your case including but now limited to background checks, verification of statements, and verification of services provided by other organizations. By signing below you understand that your signature is no guarantee of assistance. However your case will be considered for assistance. You do not have to sign, but in doing so, you will not be considered for any assistance. 


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