Appleton COTSHow to Apply

Today’s Date

Interested In:

Appleton Men’s Shelter

Appleton Women’s Shelter

Oshkosh Men’s Shelter

Referred By

First Name

Middle Name

Last Name

Other Names/Aliases Used

Date of Birth

Phone

Email

Street Address

City

County

How Long?

Do you receive:

SSI

SSDI

Unemployment

I do not receive any of the above

Employer

Start Date

Hourly Wage

Hours Per Week

What is your total monthly income?

Please check the items that apply to you:

Homeless as defined by HUD

Able to pay program fee and security deposit upon intake

Employed or have a legal source of income

Committed to retaining alcohol/drug free while in the COTS program and willing to submit to screening if suspected of use

Committed to participating in COTS’ programs, working with staff, and working toward individualized goals

Do you require special accomodations?

Yes

No

If yes, are you able to take care of yourself?

Yes

No

Does someone help care for you (Clarity Care, etc.)?

Yes

No

Have you stayed at COTS before?

Yes

No

If yes, when:

Are you a veteran?

Yes

No

If yes, what branch:

Are you on probation/parole?

Yes

No

If yes, please provide agent name and phone number:

Do you have any special conditions of probation/parole?

Yes

No

Not applicable

If yes, explain:

Do you have any pending court cases or warrants?

Yes

No

If yes, explain:

Are you under a civil commitment (mental health, etc.)?

Yes

No

If yes, explain:

Please answer the following questions to further the interview:

Why do you want to live at COTS?

How would you be a good COTS community member?

What goals do you want to achieve at COTS?

List three references (previous landlord, counselor, probation officer, employer, etc.)

Name:

Relationship:

Phone:

Address:

Name:

Relationship:

Phone:

Address:

Name:

Relationship:

Phone:

Address:

By signing, I verify the above information is accurate to the best of my knowledge, and I request to be considered for the COTS, Inc. program. I give permission for COTS, Inc. representatives to obtain and/or release information to/from the references listed above regarding my application to COTS, Inc.

Type Name:

Date:

Program	Monthly Fee
Men’s Program	$285.00
Women’s Program	$285.00
Young Adult Program	$285.00
Veteran’s Program	$285.00

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Campus of Change

How to Apply

MEAL MINISTRY VOLUNTEERS NEEDED: COOK TO CHANGE LIVES

COTS Expands into Oshkosh

COTS Summer 2022 Update!

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