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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
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Mailing address:
*
Your answer
County
*
Choose
Boone
Clay
Doddridge
Harrison
Kanawha
Monongalia
Preston
Putnam
Raleigh
Taylor
Wyoming
Other
Contact number
*
Your answer
What type of "work " are you looking for?
*
Secretarial/ Office Assistant
Custodial
Other:
Are you enrolled with your local Workforce West Virginia Office?
*
Yes
No
Required
Are you a citizen of the United States
*
Yes
No
Required
Have you ever been convicted of a felony?
*
Yes
No
Required
Monthly Income
*
Choose
SS
SSI or SSDI
Retirement
VA benefits
other
Monthly Amount received?
Your answer
Submit
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