Interest Form for the Senior Community Services Employment Program (SCSEP)
Thank you for your interest! An representative for your service area will contact you with more information upon completion of this form.
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First and Last Name *
If you answer "YES" to any of the following items OR are interested in more information, please continue filling out this form and someone will reach out to you shortly regarding eligibility. (Income guidelines apply) Check all that apply *
Required
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Email *
What is your mailing address? (Street/Po Box, City, State, Zip) *
What are the best ways to reach you? (Choose all that apply) *
Required
Income Information: List all income actually received from all sources by you, your spouse and any dependent children. Fill in the ($) amount for the LAST 6 MONTHS on the lines below. Please label income source (example: wages & salary : $12,000) Please list any social security or pensions, self employment income or unemployment insurance, or any other sources of income. *
What services are you interested in? *
Required
What County do you live in? *
Do you need an interpreter? If yes, what language *
Required
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