CONTACT INFORMATION

Legal Name:

Date of Birth: Ex: mm/dd/yyyy

Mailing Address: Apartment/Unit #:

City: State: Zip code:

Phone Number: Alternative Phone Number: Ex:602-123-4567

Email Address:

Are you a citizen of the United States?   Yes   No Are you authorized to work in the U.S?   Yes   No

Have you ever been enrolled in the program before?   Yes   No

What could hinder your ability to complete kitchen duties? (e.g.: standing for 8 hours, lifting 30-50lbs, crawling, bending,etc. If NONE please enter: "None")

BACKGROUND

Are you currently residing in a shelter?   Yes   No

Highest level of education completed?   Middle School   High School   GED   College

Do you have any regular or ongoing appointments?   Yes   No
If yes, please explain?

Have you ever been convicted of a felony?   Yes   No
If yes, for what?

Do you have any pending legal issues?   Yes   No
If yes, please explain:

In the past 90 Days have you engaged in the illegal use of drugs?   Yes   No

As part of the Community Kitchen drug testing policy you will be required to submit a drug screen test prior to entering the program. A positive drug screen test will result in a denied application. You also understand that if selected for the program you will remain drug free the entire 16 weeks. Should you test positive for a drug screen test during the program you will be dismissed.

REFERENCES

Case Manager Name: Phone #: Ext:

Agency:

Probation Officer Name: Phone #: Ext:

Professional Contact: Relationship:

Company: Phone #:

Personal Contact: Relationship:

How long have you known them? Phone #:

May we contact these references?   Yes   No

EMPLOYMENT HISTORY

*Please list the following information for your 3 most recent jobs. Include any work while incarcerated.

Employer #1: Start Date: End Date:

Job title:

Explain Job Duites:

Reason for leaving:

Employer #2: Start Date: End Date:

Job title:

Explain Job Juites:

Reason for leaving:

Employer #3: Start Date: End Date:

Job title:

Explain Job Juites:

Reason for leaving:

The information below will only be used for the purpose of scholarship and funding opportunities.

Number of people living in your Household: Yearly Household Income: $

Are you receiving any of these benefits?   Yes   No

AHCCHS Food Stamps   Cash Assistance   SSI   Unemployment  

How long have been receiving these benefits: Amount: $

ADDITIONAL INFO: Community Kitchen is a second-chance program for low income adults that may have struggled in the past with substance abuse, legal troubles, poverty, and/or homelessness.Any addition information about yourself, that you feel better qualifies you for this second-chance program (e.g. past substance abuse, physical health issues, mental health, ect.)

I I certify that my answers are true and complete to the best of my knowledge.

I understand that if I am accepted into the program I will not be paid wages for work, but will receive the benefit of life skills classes, training, and job placement assistance.

If this application leads to enrollment into the program, I understand that I may be asked to take and pass a physical examination and/or have a doctors release to participate

If this application leads to enrollment into the program, I understand that false or misleading information in my application or interview
may result in my release.

Enter your full name: