SENIOR COMMUNITY SERVICE
EMPLOYMENT PROGRAM
TELEPHONE VERIFICATION FORM
Eligibility Determination: ! Original Enrollment ! Re-enrollment ! Re-certification
Applicant/Enrollee Name:_________________________
SSN: ______________
_________________________ __________________
___________ ________
Address
City
State
Zip
Item requiring verification:______________________________________________
Comments:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date of Contact:___________
Contact Person:_____________________________ Title_____________________
Agency/Organization Name: _____________________________________________
_________________________ __________________
___________ _________
Address
City
State
Zip
Phone Number (
) ___________________
I attest that the information recorded by me on this document was obtained through
telephone contact.
_____________________________________________
_______________
SCSEP
Date
F:\Website\employ\PhoneVerification.doc