Abe Brown Interest Form

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.
1.First Name:(Required.)
2.Middle Initial:
3.Last Name:(Required.)
4.DC#(Required.)
5.Full Social Security Number:(Required.)
6.Date of Birth:(Required.)
7.Physical Address:(Required.)
8.County of Residence:(Required.)
9.City:(Required.)
10.State:(Required.)
11.Zip code:(Required.)
12.Personal email:(Required.)
13.Phone number:(Required.)
14.Alternative phone number:(Required.)
15.Gender?(Required.)
16.Have you been arrested outside of Hillsborough County? If yes, list cities and states. (Required.)
17.Have you ever been arrested for a violent or sexual crime? If yes, list charge(s) and date of charge(s).(Required.)
18.Do you currently have any disabilities or health conditions that would prevent you from working?(Required.)
19.Are you willing/able to work a fulltime job?(Required.)
20.Have you ever been diagnosed with a mental health disorder? If yes, please list diagnosis.(Required.)
21.Are you currently taking any medication? If yes, please list medication and reason for taking
medication.(Required.)
22.Have you ever received SSI/disability benefits and/or are planning on applying for benefits?(Required.)
23. Will you need assistance with transitional housing?(Required.)
24.How can Abe Brown Ministries’ inspHire Program assist you?(Required.)
25.Have you registered in EmployFlorida.com? Go to this page to register;  https://www.employflorida.com/vosnet/Default.aspx(Required.)
26.Are you a U.S. Citizen or legally authorized to work in the U.S.?(Required.)
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.(Required.)
28.Do you consider yourself to have a disability?(Required.)
29.Are you in the military, an eligible veteran, or spouse of an eligible veteran?(Required.)
30.Are you currently Active Duty military spouse who is unemployed/underemployed?(Required.)
31.Are you currently working?(Required.)
32.Rate of pay?
33.How many hours do you work per week?
34.Are you able to work full-time?(Required.)
35.Have you been convicted of a Felony(Required.)
36.If yes, please list year and location of conviction.
37.Are you pregnant or have a dependent child?(Required.)
38.Do you currently reside in a homeless shelter or are you currently homeless?(Required.)
39.Are you currently in school?(Required.)
40.If applicable, what type of school are you currently in?
41.Do you have a high school diploma?(Required.)
42.Have you completed any advanced training? Please list type and training and dates.
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?(Required.)
44.Are you currently receiving TANF/Cash assistance?(Required.)
45.Are you currently in foster care or aged out of  foster care?(Required.)
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.)(Required.)
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.)(Required.)
48.Do you file taxes by yourself or with your parents?(Required.)
49.Do you provide 50% or more of your living expenses?(Required.)
50.Type of income? (Please select all that apply)(Required.)