PORTLAND REFUGEE SUPPORT GROUP
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Request Services Form
WARNING
:
If you use your smartphone to submit this form we may not receive it. Please use a computer. Thank you!
* Note that refugees must become our clients in order for us to offer them our services.
* If you are an advocate for a refugee, please fill out your information below.
*
Indicates required field
Today's Date
*
ADVOCATE INFORMATION (if applicable)
Advocate Name *
*
First
Last
Advocate Email *
*
Advocate Phone Number *
*
APPLICANT INFORMATION (person in need of services)
Applicant Name
*
First
Last
Email
*
Phone Number
*
Status
*
Refugee
Asylee
Immigrant
Other
Which do you possess?
*
Green Card
U.S. Citizenship
Other (explain below)
OTHER *
*
How long have you been in America?
*
Country of Origin
*
All languages spoken
*
We only serve residents of Oregon and Southern Washington State. Do you live in Oregon or Southern Washington State?
*
Yes
No
Are you single or married?
*
Single
Married
How many children do you have?
*
How many family members live with you?
*
Please tell us in detail what kind of help you need
*
Submit
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Make sure you click the SUBMIT button well, until you see the confirmation message "
Thank you. Your information has been submitted
" or you see the message "
Please correct the highlighted fields
".
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