APPLY SER SCSEP A program for low-income unemployed job seekers, 55+, to build/enhance/update job skills to be able to look for and find a job. Apply Now Name(Required) (Last, First, MI)How did you hear about us?(Required) Date(Required) Rural Resident? Yes No Address(Required) City(Required) Telephone Number(Required) County(Required) State(Required) Zipcode(Required) Email Address(Required) Date of birth(Required) Age(Required) Gender Male Female Married? Yes No Number of people living at residence?(Required) Total household income?(Required) Income is... Per Month Per Year IDENTIFY PAST 6 MONTHS INCOME: Social Security (SSA, SSDI, SSI) Unemployment Help from Others Pension/Retirement Disability Benefits Educational Assistance Dividends/Interest Alimony Self-Employment/Odd Jobs Previous Salary/Earnings Net Rental Income Royalties Annuities Trusts/Estates CHECK ALL THAT DESCRIBE YOUR SITUATION: Night time residence at Shelter or transition house Night sleep-place not intended for regular sleeping Unpaid/overdue rent or mortgage Often borrow money to help pay FULL rent/mortgage/utilities Unpaid/overdue Real Estate taxes Temporary share space with family/friend & not your preference Have involuntarily moved several times in the last year Credit history or background disqualifies you from most rental/lease agreements Cannot pay FULL rent or mortgage most months Frequent unpaid or overdue electric/gas/water bills Evicted from a residence in the last 12 months Lived in a shelter at some point during the last 12 months ARE YOU(Required) A Veteran A Spouse of a Veteran Disabled Limited English Highest grade you completed? Ever participated in another training program such as WIA/WIOA?(Required) Yes No Dates Registered at the One-Stop/local employment office/American Job Center? Yes No What type of work are you looking to be trained (job training)?(Required) Do you have a resume that goes back past ten years? Yes No Rate your Basic Computer Skills Excellent Good Fair Poor Do you drive or take public transit? Car Bus Other How far are you willing to travel for training? In milesPlease Authorize The information I have provided is true to the best of my knowledge. I am aware that the information I have provided is subject to review and verification. Applicant's Signature:(Required) Date(Required) Name of individual taking this information:(Required) Date