Your Application "*" indicates required fields Step 1 of 11 - License Information 9% Do You Live In Sonoma County?* Yes No Do You Have a Current & Valid California Drivers License?* Yes No California Driver's License Number* Terms* I agree to the termsI understand that all contentions made in the application and/or the letter of nomination are subject to verification. I understand that if contention is found to be untrue or dishonest, whether intentionally or unintentionally, this could lead to forfeiture of the vehicle and any or all ongoing aid and could lead to disqualification. Thank you. Your Letter of Nomination*Please use this space to tell us about the who, what, when, where and why for your need of reliable transportation and current situation.Please use this space to tell us about the who, what, when, where and why for your need of reliable transportation and current situation. Name* First Middle Last Maiden Name and/or Other Names Used Current AgePlease enter a number from 18 to 110.GenderFemaleMaleOtherPrefer Not To SpecifyPhone*Can we text you at this number?* Yes No HiddenDaytime Phone*Email Where are you currently staying?Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Many Adults (Affiliated With You) Are Living At This Location*How Many Children (Affiliated With You) Are Living At This Location*Please enter a number less than or equal to 7. Are You Single Parent Over 65 Disabled Homeless Student Current Household Monthly Income (After Taxes)How much money do you get each month?Income Sources* Employed Calworks Calfresh SSI SSDI SS UIB Other I Have No Income Primary Mode of Transportation* Do you ride the bus, uber/lyft, get rides from friends, walk, or borrow a car? Describe your situation.How Much Do You Spend Per Month On Transportation?* Do You Have Any Medical, Criminal, or Outstanding DMV Fines or Fees That Would Inhibit Your Ability to Legally Drive?* Yes No Explain Will You Be Able to Purchase and Maintain Full Coverage on the Vehicle* Yes No How Did You Hear About the Crozat Family Foundation?* Radio 211 Friend/Family Other Have You Requested Help From Crozat Family Foundation Previously?* Yes No Approximately When Did You Last Apply* Have You Had Any Recent Unexpected Expenses*For example, car repair, medical, job loss, home repair, school. Please explain. Documentation will be required and can be submitted on the final page of this application. Tell Us About Your Vehicle Needs*Car seats, booster seats, height, special needs. How Have You Tried to Improve Your Situation And What Was The Result?* Send us documentation: Include your California driver’s license, proof of income, or any other information relating to your application.FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.Consent* ConfirmationI represent that the information provided in this application is true and correct to the best of my knowledge. The Crozat Family Foundation is hereby authorized to verify all information in connection with the processing of this application.Signature
