BEST CHANCE Indications of Interest

1. Let's Get Started!

Congratulations for making the first move on your new career path. This learn and work program is designed to help you build a self-sustainable future for you and your family.

Let's get started by answering the questions below:

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* 1. Date:

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* 2. Full Legal Name

First Name:

Last Name:

Middle Initial:

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* 3. Address:

Street Name:

Apt #:

City:

State:

Zip Code:

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* 4. Phone Number:

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* 5. Email Address:

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* 6. Are you an ex-offender?

Yes

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* 7. Are your crimes sex-related?

Yes

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* 8. Can you provide proof?

Yes

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* 9. Do you, a friend, or any member of your family have a history of Opioid Use?

Yes

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* 10. Gender

Male

Female

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* 11. Ethnic Background

African American/Black

Caucasian/White

Hispanic/Latino

Multi-Racial

Other (please specify)

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* 12. Education

High School Diploma

GED

None

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* 13. Job / Career Interest:

Construction (Carpentry, Cement Masonry, Weatherization)

Culinary (chef, food preparation, handling)

Advanced Manufacturing

Other (please specify)

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* 14. Referral Source

CWP Website

Flyer

Probation/Parole

Other (please specify)

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* 15. Are you on probation/parole?

Yes

Contact Person

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* 16. Do you reside in a halfway house?

Yes

Name of House