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CCSR Benevolence
Assessment Form

Please fill out this assessment form completely so we can accurately evaluate how to assist you.

1. Basic Information

Full Name *

Full Address (Number, Street, City, State, Zip) *

Telephone Number *

Birthdate (Month, day, year) *

Gender *

Marital Status *

2. Driver's License?

Do you have a Driver's License? *

Yes No

3. Driver's License Information

Driver's License state and number *

Please upload a copy of your Driver's License *

4. Other Forms of ID

What is your other Form of ID and ID Number? *

Please upload a copy of your ID *

5. Employment Status

Are you currently employed? *

Yes No

6. Yes, I am currently employed

Where do you work? *

How long have you worked there? *

7. Church Membership

Are you a member of a church? *

Yes No

8. Church Information

What is the name of your church? *

What is the Pastor's name? *

Do you regularly attend service? *

Yes No

9. Prayer Counselor

Would you like to speak with a Prayer Counselor? *

Yes No

10. Family Information

How many additional household family members are living with you? *

Please enter Name, Relationship, and Age for all members (if none, type N/A). Press ENTER to start a new line for each member *

11. Describe your situation

What is your present situation or need? *

What additional avenues have you pursued in resolving this matter? *

How'd you hear about us? *

Please upload a copy of the related bill/document: *

Concerned Clergy for Spiritual Renewal. Faith-led advocacy and community service for the greater Oklahoma City area since 1966.

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location_on Oklahoma City, OK
mail info@ccsrok.org

CCSR Benevolence Assessment Form

1. Basic Information

2. Driver's License?

3. Driver's License Information

4. Other Forms of ID

5. Employment Status

6. Yes, I am currently employed

7. Church Membership

8. Church Information

9. Prayer Counselor

10. Family Information

11. Describe your situation

CCSR Benevolence
Assessment Form