Answer the following questions truthfully and to the best of your ability. Any false statements will result in a denial of entry into the
program and/or dismissal from the program.

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* 1. First Name:

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* 2. Middle Initial:

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* 3. Last Name:

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* 4. DC#

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* 5. Full Social Security Number:

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* 6. Date of Birth:

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* 7. Physical Address:

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* 8. County of Residence:

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* 9. City:

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* 10. State:

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* 11. Zip code:

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* 12. Personal email:

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* 13. Phone number:

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* 14. Alternative phone number:

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* 15. Gender?

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* 16. Have you been arrested outside of Hillsborough County? If yes, list cities and states. 

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* 17. Have you ever been arrested for a violent or sexual crime? If yes, list charge(s) and date of charge(s).

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* 18. Do you currently have any disabilities or health conditions that would prevent you from working?

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* 19. Are you willing/able to work a fulltime job?

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* 20. Have you ever been diagnosed with a mental health disorder? If yes, please list diagnosis.

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* 21. Are you currently taking any medication? If yes, please list medication and reason for taking
medication.

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* 22. Have you ever received SSI/disability benefits and/or are planning on applying for benefits?

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* 23.  Will you need assistance with transitional housing?

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* 24. How can Abe Brown Ministries’ inspHire Program assist you?

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* 25. Have you registered in EmployFlorida.com? Go to this page to register;  https://www.employflorida.com/vosnet/Default.aspx

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* 26. Are you a U.S. Citizen or legally authorized to work in the U.S.?

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* 27. All males born January 1, 1960 or later are required to register with Selective Service. If applicable, have you completed this registration? To check your registration please visit sss.gov.

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* 28. Do you consider yourself to have a disability?

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* 29. Are you in the military, an eligible veteran, or spouse of an eligible veteran?

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* 30. Are you currently Active Duty military spouse who is unemployed/underemployed?

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* 31. Are you currently working?

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* 32. Rate of pay?

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* 33. How many hours do you work per week?

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* 34. Are you able to work full-time?

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* 35. Have you been convicted of a Felony

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* 36. If yes, please list year and location of conviction.

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* 37. Are you pregnant or have a dependent child?

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* 38. Do you currently reside in a homeless shelter or are you currently homeless?

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* 39. Are you currently in school?

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* 40. If applicable, what type of school are you currently in?

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* 41. Do you have a high school diploma?

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* 42. Have you completed any advanced training? Please list type and training and dates.

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* 43. Do you currently receive or are a member of a household family that receives Food stamps or received Food stamps during the previous six months?

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* 44. Are you currently receiving TANF/Cash assistance?

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* 45. Are you currently in foster care or aged out of  foster care?

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* 46. What is your family size? (This includes the total number of people in your family= all individuals in your household related by blood, marriage or court decree.)

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* 47. What is your total annualized household income before taxes? (Family income = all those living in a household related by blood, marriage or court decree.)

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* 48. Do you file taxes by yourself or with your parents?

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* 49. Do you provide 50% or more of your living expenses?

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* 50. Type of income? (Please select all that apply)

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