West Virginia Bureau of Senior Services           Senior Community Service Enrollment Program Enrollment Application                                                  Coordinated by: Preston County Senior Citizens, Inc.                                                                              
Please submit ONLY one application.

For questions or assistance please call 304.558.3317


Sign in to Google to save your progress. Learn more
Email *
First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Mailing address: *
County *
Contact number *
What type of "work " are you looking for? *
Are you enrolled with your local Workforce  West Virginia Office? *
Required
Are you a citizen of the United States *
Required
Have you ever been convicted of a felony? *
Required
Monthly Income *
Monthly Amount received?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of West Virginia. Report Abuse