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 (Required.)

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

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2. Full Name (Required.)

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

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3. Current Address (Required.)

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4. Type of Housing (Required.)

Enter a phone number where you can be reached.

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5. Phone Number (Required.)

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7. Preferred Mode Of Communication

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8. Country of Origin (Required.)

Enter the date you first arrived in the United States

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9. U.S. Date of Arrival (Required.)

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 (Required.)

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.) (Required.)

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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) (Required.)

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14. Primary Language (Required.)

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15. Do you need an interpreter? (Required.)

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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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