SCSEP Pre-Application

Senior Community Service Employment Program

Pre-Application Survey

The SCSEP matches eligible older adults with PART-TIME employment training at community service organizations.

To be considered for enrollment in SCSEP, individuals must:

Be at least 55 years or older
Be currently unemployed
Meet low income eligibility family guidelines for the past 12 months
Reside in Rhode Island (Bristol, Kent, or Providence County)

Directions: Please complete the following pre-application to be considered for the Senior Community Service Enrollment Program (SCSEP). Once you have submitted the pre-application, a SCSEP staff member will contact you regarding your eligibiltity.

Name*

First NameLast NameSuffix

Last 4 Digits of Social Security Number:*

Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Mailing Address (if different than above):

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

Date of Birth:*

Date

Date of Birth*

Date mm-dd-yyyy

Gender:*

Email

example@example.com

Highest Level of Education:*

Please check all that apply:*

Are you currently employed:*

If you answered yes to the previous question, please do not continue completing this application as you must be unemployed to be eligible for this program.

Last Employer:*

Company Name

Last Day of Employment:*

Date

Last Day of Employment*

Date mm-dd-yyyy

Job Title at last employment*

Are you currently involved in volunteer work?*

If yes, how many hours per week?

Hours per week

Type of Employment Seeking:*

List type of employment including full ot part time as well as interest areas

Barriers to Employment: Please check all that apply*