Top Grooming Service Application

Gender

Male Female Nonbinary Prefer not to say

Primary Phone Number

Alternative Phone Number

Drivers License Number

Marital & Family Status

Marital Status

Spouse’s Phone Number

Number of Dependents

Names & Ages of Dependents

If renting

Landlord’s Name

Landlord’s Contact Number

Barbershop Relationship

Do you regularly patronize [Barbershop Name]?

Yes No

If yes, how long have you been coming?

Applicant Employment

Spouse’s Employment

Other Household Employment

Is anyone else in the home employed?

Yes No

If yes, list names and employers

Additional Sources of Income Please check all that apply

Monthly Income Total($)

Do you have family who can help you financially?

Yes No

Are you currently unemployed?

Yes No

If Yes(Unemployed)

How long have you been unemployed?

Why are you unemployed?

What steps are you taking to seek employment?

Requested Services (check all that apply)

Adult Haircut Kid Haircut Shave Other

What led to you needing this assistance?

How do you plan to meet this financial obligation going forward?

Have you seen a financial counselor within the last six months?

Yes No

Are you willing to meet with a Budget Coach?

Yes No

Have you sought assistance through the barbershop before?

Yes No

Please list two individuals (not relatives) who can vouch for you

Certification

By signing below, I attest to the fact that I fully understand the information being requested from me in this application process and that, to the best of my knowledge, I have provided accurate and honest responses.

FADES & ARCHES BARBERSHOP

Community Assistance Haircut Program

Grooming Service Assistance Application

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