Telephone Verification Form - Senior Community Service Employment Program printable pdf download

Telephone Verification Form - Senior Community Service Employment Program

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

Telephone Verification Form - Senior Community Service Employment Program