Request Services Form

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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.

الرجاء تعبئة الطلب باللغة الإنجليزية على الكمبيوتر وليس على الهاتف المحمول
إذا احتجت إلى مساعدة في تعبئة النموذج، فضلاً تواصل مع السيدة آلاء على البريد الإلكتروني أدناه
ala@pdxrsg.org
أو أرسل رسالة نصية إلى الهاتف أدناه
971-427-0173

* 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 * *

What resettlement agency did you initially arrive through? (IRCO, SOAR, Catholic Charities, Lutheran Community Services, Salem for Refugees, other) If you arrived on your own, please enter "N/A" *

What was the date of arrival in the United States? *

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

∙ 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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Request Services Form​

Request Services Form