NC Participant Reverse Referral Form

More Than A Job NC Interest Form
Thank you for your interest in The HELP Center's More Than a Job-NC Program. Please complete all required fields below. To participate in this program, you must currently be receiving SNAP (Food and Nutrition Services) benefits.

If you are not currently receiving SNAP benefits, please contact our office. Our team can provide information and assistance regarding the SNAP application process.

Once your interest form is submitted, The HELP Center will verify your eligibility for participation. A member of our Case Management Department will then contact you to discuss the next steps and, if eligible, begin the enrollment process.

If you need immediate assistance or have questions regarding your eligibility, please contact our office at (980) 486-9054. We look forward to supporting you on your path to employment and career success.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Last 4 of SSN
Date

MonthDayYear
Date
Referral Partner Name
Referral Partner Email
example@example.com
REFERRAL RESULT (To be completed by NCDHHS or local DSS)
I understand that this is a voluntary program, and it does not affect my FNS benefits. While I understand that this is a voluntary program, I agree to fully participate in order to increase my chances of finding employment or getting a better job.
Participant Signature
Date

MonthDayYear
Date
Mailing Address (Include City, State and Zip)
County Email
example@example.com
Sender Name
Should be Empty:

More Than A Job NC Interest Form