Senior Community Service Employment Program Interest Form
You must be 55 or older, household income at 125% of poverty guideline, unemployed, and living in Adams, Allen, DeKalb, Huntington, or Whitley to qualify.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County you currently reside in:
Please Select
Adams
Allen
DeKalb
Huntington
Whitley
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Age
Referred by (how did you hear about this program?
Previously enrolled in SCSEP program?
Yes
No
Please attach your resume
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What is your monthly family income?
Number of family living in your household?
Are you currently employed?
Yes
No
Are you a veteran or spouse of a veteran?
Yes
No
Do you have difficulty reading, writing, or speaking?
Yes
No
Are you currently receiving SSI, SSDI, or Social Security Retirement options?
Yes
No
Are you old enough for, but not receiving Social Security?
Yes
No
Are you considered disabled (receiving SSDI or Doctor Diagnosis)?
Yes
No
Do you have low employment prospects?
Yes
No
Are you late on your rent or utilities?
Yes
No
Are you homeless?
Yes
No
Did you grow up speaking a language other than English?
Yes
No
Do you receive services at workOne, but are still unemployed?
Yes
No
Are you over 65?
Yes
No
Please sign if you agree that the above information is correct to the best of your knowledge and belief.
Submit
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