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 Name Last Name Suffix
Last 4 Digits of Social Security Number: *
Address: *

Street Address

Street Address Line 2

City State

Zip Code
Mailing Address (if different than above):

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Date of Birth: *

Month Day Year
Date
Date of Birth *
Date mm-dd-yyyy
Gender: *
Email
example@example.com
Highest Level of Education: *

Less than High School Some High School High School Diploma Some College College Graduate
Please check all that apply: *

Homeless At Risk of Homelessness Veteran Spouse of Veteran Limited English Disabled None 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: *

Month Day Year
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 *

Computer/Keyboarding Skills Lack of Office Experience Lack of Transportation No GED/Diploma Low Self-Esteem Ex-Offender None Apply

In order to qualify for the Senior Community Service Employment Plan, you must meet certain income eligibility guidelines. The questions below will allow the RI Department of Labor & Training to pre-qualify you for the program if you meet the income guidelines.
Marital Status *
How many dependents do you have?: (if none, enter 0)? *
Enter the income amounts for the last six (6) months for you, your spouse, and dependents in any of the fields that apply.
Wages from a Job:
Social Security Survivor Benefits:
Social Security Retirement:
Other Pension or Retirement:
Interest Income:
Dividends:
Alimony:
Rents, royalties, estates, & trusts:
Other Income:
Ex: SSDI, SSI, Public Assistance, etc.
Source of Other Income
Source of Income
What was your approximate total family income for the last 6 months?: *
How did you hear about SCSEP?
Should be Empty:

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