SCSEP Pre-Application

The NICOA Senior Community Service Employment Program offers part-time paid work experience training in community agencies for older individuals who have limited incomes. Eligibility is based on age and total family income, and most-in-need characteristics. Those who are veterans, over the age of 65, and documented most-in-need are given preference for selection to be enrolled in SCSEP.

Please complete the following questionnaire and return it to a NICOA SCSEP office. This information will be used to screen your eligibility to apply for enrollment in SCSEP. If you appear to be eligible and there are openings in the NICOA SCSEP, someone on our staff will contact you to complete a full application. When you are contacted to complete a full application, you will be required to provide written documentation of age, total family income, and other characteristics.

THANK YOU for providing accurate information. Completion of this questionnaire does not mean that you are eligible or selected for SCSEP enrollment. For further information and submission of this pre-application, contact your local NICOA SCSEP office. All information will be kept confidential.

SCSEP Pre-Application Questionnaire

1) Name
First Last
2) Phone
3) Address
Street Address Address Line 2 City State ZIP Code
County
4) Do you have an email address?
5) Date of Birth
MM
DD
YYYY
Current Age
6) Are you or your spouse a Veteran?
- Yes
- No
7) Family Size: How many persons are in your household (including yourself)?
Please enter a number greater than or equal to 1.
Marital Status
- Married
- Single
8) What is your estimated total annual family income?
9) Are you disabled?
- Yes
- No
10) Do you receive any payments from public assistance (SSI, other) or disability income (SSDI)?
- Yes
- No
11) Do you live in a rural area?
- Yes
- No
12) Is your ability to speak or write in English limited?
- Yes
- No
13) Are you currently homeless or at risk of homelessness (late in rent or mortgage payments)?
- Yes
- No
14) Have you completed high school or obtained a GED certificate?
- Yes
- No
15) How long have you been looking for employment
16) Have you registered and failed to find employment through a One-Stop Career Center?
- Yes
- No
17) How did you hear about the NICOA SCSEP training program?
Signature
Please type in your full name to confirm the information above is true and correct to the best of your knowledge.
Date
Date Format: MM slash DD slash YYYY

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