• Urban Seniors Jobs Program - Application Form

    Pinellas County Urban League form with personal information, income, equipment/digital skills, characteristics, public assistance, barriers, related program enrollment, job interests, and certification.

  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Current Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Have you been employed in the past 6 months?*
  • Date last worked
     - -
    2 digit month, 2 digit day, 4 digit year
  • Former Senior Community Service Employment Program (SCSEP) Participant?*
  • Exit Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • All Income Before Deductions

  • Social Security Income Types*
  • Pension Received?*
  • Veterans Benefits Received?*
  • Child Support Received?*
  • Alimony Received?*
  • Unemployment Compensation Received?*
  • Employment Income Received?*

  • Education and Digital Skills Level

  • Equipment Access*
  • Broadband Internet at Home?*
  • Digital Skill Level*

  • Characteristics

  • Veteran Status*
  • Individual with a Disability*
  • Received services funded by State Development Disabilities Agency (SDDA)*
  • Homeless (Lack a fixed, regular, and adequate nighttime residence i.e. couch surfing)*
  • At Risk of Homelessness (You may be at risk of becoming homeless due to difficulty maintaining your current housing, for example, behind on rent or facing eviction)*
  • Failed to Find Employment After Using Workforce Innovation and Opportunity Act (WIOA) Title*
  • Do you have difficulty reading, writing, or understanding written information that may affect your ability to find or keep employment?*
  • Low Employment Prospects (You have limited employment opportunities due to barriers that make it difficult to find or retain employment.)*
  • Formerly Incarcerated: You have a history of Incarceration in the past 5 years.*
  • Severe Disability (You have a documented disability that significantly affects your ability to work or perform major daily activities.)
  • Frail (Do you need assistance with daily activities such as walking, dressing, bathing, shopping, or managing household tasks?)*
  • 75 or Older*
  • Old Enough but not Receiving SS Title II (You are eligible for Social Security retirement benefits but are not currently receiving them.)*

  • Public Assistant

  • Receiving Temporary Assistance for Needy Families (TANF)
  • Receiving Supplemental Nutrition Assistance Program (SNAP)
  • Subsidized Housing (You currently live in housing that is partially paid for or supported by a government housing assistance program)
  • State or Local Welfare Recipient*
  • Other Public Assistance Recipient*

  • Barriers to Employment

  • Ex-Offender Status (Have you ever been convicted of an offense or involvement with the criminal justice system that may limit your employment opportunities.)*
  • Greatest Social Need (You have a disability, language barrier, or experience isolation that makes it difficult to perform daily activities, access services, or live independently.)*
  • Displaced Homemaker (Provides unpaid care for family members at home and is unemployed, underemployed, or has lost financial support, including military spouses affected by deployment, relocation, or service-connected death or disability)*

  • Enrollment in Other Program Services

  • WIOA Adult Formula Program*
  • Title II Adult Education (WIOA)*
  • National Farmworker Jobs Program*
  • Indian and Native American Program*
  • Veterans Program*
  • Vocational Education Program*
  • WIOA Vocational Rehabilitation Program*
  • Wagner-Peyser Employment Service Program*
  • Receiving Employment and Training Services Related to SNAP*
  • Other WIOA or Non-WIOA Programs*

  • Interest Job Code

  • Interest Job Code (select at least 3)*

  • What is Sector-Based Training?

    • Workforce development strategy.
    • Prepares job seekers for careers in a specific industry or sector.
    • Provides industry-specific skills needed for employment.

    Sector-Based Training prepares you for a career in a specific industry by teaching you the skills employers are looking for. It provides industry-specific training to help you become job-ready and increase your chances of finding employment.

  • Are you interested in sector-based training?*

  • Certification

  • I hereby certify that the above information is true and accurate to the best of my knowledge. I understand that if I intentionally provide inaccurate information, I may be terminated from the SCSEP Program and may be subject to legal penalties.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: