APPLICATION FOR ASSISTANCE – The Dignity of Work

To be considered for financial assistance, you must fill out the application below.
We give priority to people graduating from a substance use disorder recovery program, or who have been released from incarceration.
Once your application is reviewed, you will be notified of one of the following decisions by the Board of Directors:
1) We need more information,
2) We want to schedule an interview with you, or
3) We have declined your application.

Items marked with an asterisk (*) must be filled in.

Personal info

Name*

First Last

Address*

Street Address

City*

State*

Zip Code*

Email address where you can be reached*

Phone Number*

Alternate Phone Number

Ethnicity*

Gender*

Race*

Age*

What kind of work are you looking for in the next 1-3 years?*

Minimum of 100 characters and Maximum of 3000 characters

What resources or assistance do you need to help get a job?*

Please mention if the resource is not listed above

Prior Work Experience ? Upload Resume

Max. file size: 32 MB.

Either attach a resume, or fill in the form below with your prior work experience; explain any gaps in work experience; go back to your last 4 jobs and gaps or 7 years.

Most Recent Job or Career

From (mm/yyyy)	To (mm/yyyy)	Your Job, Title, or Position	Reason For Leaving

Click on the Plus icon on the right side to add more rows

Education: College, Technical or Trade School

Name of School	From (mm/yyyy)	To (mm/yyyy)	Degree, Certificate, or License

Personal References * Provide at least 3 work and personal references. Note for each person their relationship to you (e.g. friend, counselor, boss, subordinate, co-worker, family member, clergy, etc). Provide a phone and email for each one if available. Limit family references to one person. Be sure to include at least one work reference. Please advise each person below that we may be contacting them on your behalf.

Name	Relationship	Phone	Email

Have you been convicted of a felony in the past 5 years?

Yes
No

Do you have gaps in your employment in the past 5 years?

Yes
No

Do you have stable housing including a safe and reliable place to sleep each night?

Yes
No

For what year did you last file a Federal income tax report?

What was your taxable income that year?

Have you applied for any jobs in the past 6 months?*

Yes Fill out the form below
No Skip this section and click Submit

Starting with the most recent job applied for, provide the following information.*

Job applied for	Company	Results (Hired/Rejected/Interviewed)