1. How did you hear about the Mother's Day Giveaway? * FriendFacebookTwitterFlyerNew Jerusalem member


2. YES, please provide me information about events, news and updates for (check all that apply) * Community C.A.R.E.New Jerusalem

1. Name *


2. Address (please include Apt. No. if applicable) *


1. City *
2. State / Province / Region * AL AlabamaAK AlaskaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFL FloridaGA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaOH OhioOK OklahomaOR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
3. Zip *


1. Phone Number *
2. Email address *

1. Total number of household members (including you) *


2. Total YEARLY household income $0 - $ 9,999$10,000 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000 - $59,999$60,000 - $69,999$70,000 - $79,999$80,000 - $89,999$90,000 - $99,999$100,000 +

Please list your household members, relationship and ages

Choose three words that you feel best describe you

1. *
2. *
3. *



1. Tell us why you chose those three words to describe yourself * * 1000 characters left


2. Why a vehicle is needed? * * 1000 characters left


3. How would transportation impact your future? * * 1000 characters left



4. What are your goals for the next 5 years? How would having transportation help you reach those goals? * * 1000 characters left

Are you willing to AUTHORIZE A PERSONAL BACKGROUND CHECK?YesNo


1. BY CHECKING THIS BOX: :
   •       > I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS PROVISIONS AND REQUIREMENTS
   •       > I ACKNOWLEDGE THAT I HAVE SUBMITTED THIS DOCUMENT VOLUNTARILY
   •       > I ATTEST THAT THE ANSWERS AND INFORMATION THAT I HAVE PROVIDED THEREIN ARE TRUE
   
   

NOTE: The Submit Application button will not function unless ALL the fields are answered. Please review your answers and make sure you have ANSWERED EVERY QUESTION appropriately before attempting to press Submit Application.