To qualify for services under this program, you must hold one of the eligible immigration or legal statuses and be a current resident of North Dakota.
Select the immigration or legal status that matches your current documents. You must have one of these statuses to receive services.

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* 1. Eligible Legal Status

Enter your full legal name as shown on your official documents.

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* 2. Full Name

Enter your full address where you are currently living in North Dakota.

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* 3. Current Address

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* 4. Type of Housing

Enter a phone number where you can be reached.

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* 5. Phone Number

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* 7. Preferred Mode Of Communication

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* 8. Country of Origin

Enter the date you first arrived in the United States

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* 9. U.S. Date of Arrival

Date
Enter the date you arrived in North Dakota. If you moved from another state, use the date you came to North Dakota.

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* 10. N.D. Date of Arrival

Date
Select “Yes” if your spouse, children, or other relatives living with you also need help.

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* 11. Do you have any family members with you who also need assistance? (If yes, please complete question 12.)

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* 12. How many family members, including yourself, are in your household?

Check all the services you would like help with. You may select more than one. Choose “Other” if you need a service that is not listed.

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* 13. Select all services you are seeking (Select all that apply)

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* 14. Primary Language

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* 15. Do you need an interpreter?

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* 16. Referring Individual or Agency

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* 17. Referring Individual or Agency Contact Information

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* 18. Any additional information you would like to provide

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