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  • Application is good for 60 days from application date. After 60 days a new application must be submitted.

  • Applicate Date
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is Your Mailing Address same as Residence Address?
  • How did you hear about us (check one)?
  • Are you a former SCSEP Participant?
  • Do you engage in any volunteer work at this time?
  • Do you have a valid Driver's License?
  • Employed at the time of application?
  • Receiving public assistance? (Check as many as apply for APPLICANT only)
  • Race: (Check as many as apply)
  • Ethnicity: (Hispanic, Latino, or Spanish origin?
  • U.S. Citizen?
  • Gender
  • 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.

  • EMPLOYMENT/TRAINING INFORMATION

  • 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)
  • Have you ever received services from Opportunities for Ohioans with Disabilities/BVR?
  • 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.)
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  • BARRIERS TO EMPLOYMENT

  • What may prevent you from getting a job? (Check all that apply.)
  • Are you currently homeless?
  • Are you at risk of homelessness? Check all that apply to you at the time of this application:
  • 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?

  • WORK HISTORY:

  • Please be sure to fill out this section in detail listing most recent employer first. Jobs in the past year must show month/day/year, for example 1/17/2024. No matter how long ago, last 3 jobs must be completed even if you have a resume.

  • From Date
     - -
  • To Date
     - -
  • From Date
     - -
  • To Date
     - -
  • From Date
     - -
  • To Date
     - -

  • Certification: I hereby certify that the above information is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information, I may be terminated from the SCSEP program and may be subject to legal penalties. I am aware that this information will be used solely for the SCSEP program including but not limited to determining eligibility, assessing suitability, and constructing an Individual Employment Plan for obtaining longterm
    employment. I acknowledge that any personal identifying information collected will be used solely for grant purposes for the Senior Community Service Employment Program and I release the use of this information for such purposes. I am aware of my responsibility to seek unsubsidized employment if enrolled in SCSEP.

  • CONFIDENTIAL STATEMENT OF INCOME

  • 1. Please indicate monthly gross amount for self, spouse, and dependents

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  • CONFIDENTIAL STATEMENT OF INCOME

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

  • On this date, I, (name of applicant), 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:     

  • 3. Applicant Certification - Read and sign below
    I certify that the income listed on the form is all my household income. I understand that it will be used to assess my eligibility for enrollment into the Senior Community Service Employment Program (SCSEP). I acknowledge that any personal identifying information collected by VANTAGE Aging will be used for grant purposes with the Senior Community Service Employment Program and I release the use of this information for such purpose. I understand that completing this form
    does not guarantee my enrollment in the program.

  • Third Party Attestation Number in Family

  • **This Page requires witness signature. You can print this form to get witness signature and upload it in the last step if you don't have the witness with you at the time of filling out this form. Witness cannot be someone living with you.

    Click Here to download.

  • I hereby certify that I, (applicant name) am a household of (list how many members)

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  • Applicant Signature Required

    I attest that the information stated herein is true and accurate, and I understand that this information, if misrepresented or incomplete, may be grounds for immediate exit from the Senior Community Service Employment Program (SCSEP) and/or penalties as specified by law.

  •  **Witness Signature Required:  

    (May be a friend, relative, housing manager, etc.  May NOT be a someone who lives with the applicant.)

    I attest that the above named applicant resides with the people listed above.

  • 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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