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Application
zenfocustech
2026-07-23T11:23:25-07:00
Adult Application Submission Form
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Name
*
First
Middle
Last
Main Phone Number
*
following prison for
Alt Phone or Message Phone (Optional)
*
Email
*
Street Address
*
City
*
State:
*
Zip Code
*
Mailing Address (if different)
City
State
Zip Code
What is your first language?
*
Do you have any children?
*
Yes
No
If yes, how many children?
Gender
*
Male
Female
Non-Binary
Other
Date of Birth (Month/Day/Year)
*
Identification / Driver's License Number
*
State of Identification
*
Is your license current?
*
Yes
No
Is your license suspended?
*
Yes
No
Do you have a Hardship Permit?
*
Yes
No
If suspended, what do you need to do to get it reinstated?
Please provide printed name, phone number, email and city/state of the three contact persons. People who will know how to reach you and indicate their relationship to you (Mother, Brother, Friend, Etc.)
Name 1
*
Relation
*
Phone
*
Name 2
*
Relation
*
Phone
*
Name 3
*
Relation
*
Phone
*
Which of the following best describes your race/ethnicity? (Check all that apply)
*
African American or Black
Native Hawaiian or Pacific Islander
Asian
LatinX/Hispanic
White, not of HIspanic origin
Native American/Alaskan Native
If a member of a Federally Recognized Tribe, which one?
What is your marital status?
*
Married
Domestic Partnership
Married-Separated
Divorced
Single - No Dependents
Single - Head of Household
Please check all that apply
Veteran
Refugee or immigrant
LGBTQ2SIA+
Currently in military or reserve
Person with disability
Do you have permanent housing?
Yes
No
If no, please describe your housing situation
How many people live in your household?
*
How many dependents/children live in your household?
*
Do you work with other programs?
*
Yes
No
If yes, which programs? (Please include program names, case manager names and phone numbers
Do you have a criminal history?
*
Yes
No
Are you currently on probation/parole?
*
Yes
No
If yes, please print the name and contact information for your parole/probation officer
What offense resulted in your most recent prison or jail stay? (Ex: Possession of controlled substance, theft, etc.)
What is your employment status at this time?
*
Never employed
Part-Time
Full-Time
Unemployed
Please provide the following information for your current OR most recent employment
Company Name
Job Title
Start Date (Month/Day/Year)
End Date (Month/Day/Year)
Wage per Hour
Hours per Week
Weekly Income
Annual Household Income
Other Income
Please check "No Benefits" or all that apply
*
No Benefits
Health/Medical
Dental
Disability
Life Insurance
Retirement/Pension Plan
Do you or anyone in your househole receive assistance of the following types? (Check all that apply)
*
No Assistance
SNAP (food stamps)
TANF (Cash assistance)
Unemployment benefits
Public Housing/Section 8 Housing Assistance
Medicaid (Oregon Heath Plan, Washington Apple Health)
What is the highest grade or year of school you have completed?
*
Some College
High School graduate
GED Graduate
Working on GED (answer questions below)
Other
How many terms completed (if some college)?
Up to 1 year
Between 1 and 2 years
Between 2 and 3 years
Between 3 and 4 years
Other
Highest grade completed (if GED Graduate or Working on GED)?
7
8
9
10
11
Other
Which GED Tests have you completed (if working on GED)?
Mathematical Reasoning
Reaasoning Through Language Arts
Social Studies
Science
None
Trades of interest (check all that apply)
Carpenter
Cement Mason
Electrician
Plumber
Heavy Equipment Operator
Laborer
Mechanic
Painter
Pile Driver
Other trades of interest:
Any additional items we should know?
Please read and sign your name below
*
- I understand that upon acceptance into Constructing Hope, I am making a three year commitment to remain in contact with program staff for ongoing support and career advancement services. I agree to report my income (wages and hours worked) to the program staff every quarter. I hearby certify to the best of my knowledge that the information given herein is true and accurate and I understand that the information I have supplied is subject to verification.
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