Project Scope Application

Please complete this form to apply for the Project Scope Transition Program.

Applicant's Name Applicant's Name First Last
Birthdate Birthdate / MM / DD YYYY
Social Security Number
Recent Address Information Recent Address Information
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
State Issued ID Number (Drivers Licenses or State Issued ID)
ICE Name (NA if None)
Email Address
Your Mobile Number Your Mobile Number - ### - ### ####
Faith
Marital Status
Do You Need Medical Care?
Are You Disabled?
Do You Receive Financial Assistance from Any Person or Agency?
If Yes on Receiving Financial Assistance, Who?
Are you Employed?
If Employed. What is the Employer's Name?
If Employed, How often are you Paid?
If Employed, What Shift(s) Do You Work?

If Employed, What Shift(s) Do You Work? First Shift Second Shift Third Shift Floater Shift
Do you have any addictions? (e.g Drugs, Alcohol, Tobacco, or etc.)
If Drug Addiction, When was last time you partake in the addiction?
Are you taking any prescribed medications and if so what?
Do you have outstanding warrants?
Are you on Probation or Parole?
Are you a Sex Offender?
Have you been convicted of any violent crimes?
Why are you interested in living at Project Scope?
Legal Statement
Please be advised that you are under no obligation to live here unless you have been released to our custody through the judicial court system. PROJECT SCOPE is a non-profit recovery empowering, transitional housing to provide an opportunity to men to reenter the community with the necessary tools to succeed. We are not government funded, but rely on donations, grants, and residents housing fees to make our services available. All of this information has been fully explained and I agree to all the contents. Please return application to: PROJECT SCOPE 1333 West Lusher Ave. Elkhart, Indiana 46517, or projectscope1333@gmail.com. TEL: 574-333-2949 WEBSITE: projectscope1333.org
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