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  • SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP)

    Application for Eligibility/Initial Assessment

  • Before you begin, please read these helpful tips to make your application smooth and successful:

    • Ohio Residents Only: This application is only for Ohio residents living in our serviced area. [Click here to check our county list].
    • Moving Between Pages: Only use the Next, Save, and Back buttons at the bottom of the application screen.
    • ⚠️ Important Note: Please do not use the back arrow button at the very top of your internet browser (like Edge, Chrome or Safari). Using your browser's back button may erase the information you just typed on that screen.
    • Saving Progress: If you would like to save your progress and finish later then please click on the Save button and create a free Jotform account to be able to come back and finish later.
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  • Documents Needed for Application to be complete

    In order for an application to be complete, the following documents are needed:

    1. Your valid Driver’s License or State ID Card
    2. Proof of Address if different from what is on your Driver's license or State ID Card.
    3. Your signed Social Security Card
    4. DD-214 for Veterans (if applicable)
    5. Proof of income for all household members for the last (6) months, for example:Social Security benefit letters
      1. Pay stubs
      2. Unemployment Compensation-Statements or printout
      3. Public Assistance or Welfare Payments- printout
      4. Veteran Payments-Statement from VA
      5. Pension or retirement income statements

    If you have any questions, please call Vantage at 330-253-4597.

  • If something does not apply please write "N/A". Application is good for 60 days from application date. After 60 days a new application must be submitted.

  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • Today
     - -
  • Is Your Mailing Address same as Residence Address?
  • Format: (000) 000-0000.

  • Number in Family

    Please list all members of your household (print whole name, relationship, and age of each person), beginning with Applicant: [relationship means self, spouse, son, granddaughter, etc.] Do not list roommates or significant others if not married.
  • Rows
  • Are you a former SCSEP Participant?
  • How did you hear about us (check one)?
  • Do you engage in any volunteer work at this time?
  • 0/200
  • Employed at the time of application?
  • Receiving public assistance? (Check as many as apply for APPLICANT only)
  • Race: (Check as many as apply)
  • Are you a U.S. Citizen?
  • Veteran? Or Eligible Spouse of a Veteran? If yes, bring a copy of your or your spouse’s DD-214 (Check all that apply)

  • *Eligible Spouse: The spouse of any of the following individuals:

    • Any veteran who died of a service connected disability.
    • Any veteran who has a total disability resulting from a service-connected disabikity.
    • Any Veteran who died while a disability so evaluated was in existence.
    • Any member of the Armed Forces serving on active duty, who at the time of application has been listed by the Secretary for more than 90 days as missing in action, captured in the line of duty by a hostile force, or forcibly detained or interned in a line of duty by a foreign.

  • EDUCATIONAL INFORMATION

  • Check the education level you have achieved
  • Check all the degrees that you have received.
  • 0/20

  • EMPLOYMENT/TRAINING INFORMATION

  • Do you have a valid Driver's License?
  • How will you get to work?
  • Do you need benefits?
  • What are you willing to work? (Check all that apply)
  • Are you looking for?
  • Have you registered at OhioMeansJobs?
  • Are you working with any other agencies to help you get a job?
  • If yes, which Agencies? (check all that apply)
  • Do you have highspeed internet that you could connect an internet capable device?
  • Do you have a computer, tablet or other device able to connect to high speed internet?
  • What are the top 3 things you value most in a job? (Check only 3.)
  • What are your top 3 job interests? (Check only 3.)
  • 0/40
  • Rows

  • BARRIERS TO EMPLOYMENT

  • What may prevent you from getting a job? (Check all that apply.)
  • Are you at risk of homelessness? Check all that apply to you at the time of this application:
  • Are you currently homeless?
  • Do you have a Disability? (check all that apply)
  • Would assistance with any of the following items help you find or maintain employment?
  • Have you ever been convicted of a misdemeanor?
  • Have you ever been convicted of a felony?
  • Have you been incarcerated and released from prison or jail at any point within the last 5 year?
  • 0/20
  • Have you been under post-release supervision at any point within the last 5 years?
  • 0/20

  • WORK HISTORY:

  • Please be sure to fill out this section in detail, listing the most recent employer first. Jobs in the past year must show month/day/year, for example, 1/17/2026. No matter how long ago, the last 3 jobs must be completed, even if you have a resume.

  • From Date
     - -
  • To Date
     - -
  • 0/100
  • From Date
     - -
  • To Date
     - -
  • 0/100
  • From Date
     - -
  • To Date
     - -
  • 0/100

  • HOUSEHOLD INCOME

  • Please enter the monthly gross amount for each type of income for self, spouse, and dependents for the past six (6) months:

  • Rows
  • Rows

  • If no income is received, please complete the following:

  • On this date, I certify that my “household income” (the combined income of my current family members, including myself, my husband, wife, and/or dependent children or grandchildren, if applicable) was zero for the past:

  • Applicant Declaration and Authorization:

    I certify that the information and household income provided on this form are true and accurate to the best of my knowledge. I understand that this information will be used by Vantage to determine my eligibility, assess
    my suitability, and build an Individual Employment Plan for the Senior Community Service Employment Program (SCSEP).


    I acknowledge that any personal identifying information collected will be used solely for SCSEP grant purposes, and I release its use for these purposes.


    Finally, I understand that completing this form does not guarantee enrollment, that I am responsible for seeking unsubsidized employment if enrolled, and that intentionally providing inaccurate information may result in termination from the program and legal penalties.

  • Find Current Date
     - -
  • Date Signed
     - -

  • Upload Needed Documents Below

  • In order for an application to be complete, the following documents are needed:

    1. Your valid Driver’s License or State ID Card
    2. Proof of Address if different from what is on your Driver's license or State ID Card.
    3. Your signed Social Security Card
    4. DD-214 for Veterans (if applicable)
    5. Proof of income for all household members for the last (6) months, for example:
      • Social Security benefit letters
      • Pay stubs
      • Unemployment Compensation-Statements or printout
      • Public Assistance or Welfare Payments- printout
      • Veteran Payments-Statement from VA
      • Pension or retirement income statements

    If you have any questions, please call Vantage at 330-253-4597.

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