Please complete this application accurately and legibly. The information provided here will be used by Freestore Foodbank staff to better understand each potential trainee's situation and needs. All information will remain confidential.

PERSONAL INFORMATION:

Name:

MaleFemaleOther

DOB:

Email Address:

Phone Number:

Current Address:

City:

Zipcode:

SSN#:

Are you a U.S. citizen?
YesNo

INFORMATION ON HOUSEHOLD, TRANSPORTATION & LIVING SITUATION

Specify current housing status:
OwnRentStaying with friend/familyTransitional shelterHomelessOther

If in homeless or transitional shelter, please specify where:

Current relationship status:
SingleMarriedDomestic Partnership

Are you the head of your household?
YesNo

How many children:

Ages of children:

ELIGIBILITY REQUIREMENTS:

All instruction and testing for this program is conducted in English. Are you able to read, write and communicate in English proficiently?
YesNo

Are you able to regularly perform required warehouse duties as assigned for a 8 hour day? Including but not limited to:
  • Standing for long periods of time
  • Ability to bend and lift a minimum of 50lbs
  • Able to drive and operate powered equipment safely

YesNo

ADDITIONAL INFORMATION:

How did you hear about the LIFT the TriState program?
Gateway CollegeCustomer Connection Center, Freestore FoodbankFacebookFriend/FamilyBelflexOther

Other:

Why are you interested in this program? (2-3 sentences):

EMERGENCY CONTACT INFORMATION

Name:

Relationship to you:

Phone Number:

EMPLOYMENT HISTORY:
(Please provide complete information on your last three jobs, starting with the most recent. Note: Warehouse experience is not a requirement for admission into the LIFT the TriState program).

Employer (Company Name):

Name of Supervisor:

Supervisor's Phone#:

Job Title:

Duties/Responsibilities:

Start Date:

End Date:

Reason for Leaving:

-------------

Employer (Company Name):

Name of Supervisor:

Supervisor's Phone#:

Job Title:

Duties/Responsibilities:

Start Date:

End Date:

Reason for Leaving:

SOCIAL SERVICES INFORMATION:

Do you have a Case Worker/ Case Manger?
YesNo

Name:

Agency:

Phone#:

Email:

Do you currently have a source of income?
YesNo

Please select the source(s) of income you currently receive:
EmploymentFamily SupportUnemploymentSocial SecuritySocial Security DisabilityOther

Other (Please explain):

Are you currently receiving any of the following benefits or services?
Food StampsMedicaid/AHCCCSCash AssistanceSSIUnemployment BenefitsOtherNone

Other (Please explain):

The staff at Freestore Foodbank wants to help all those who are enrolled in the program become as healthy, independent, and self-sufficient as they can be. Please select any areas that you need assistance with:

Medical CareMental HealthSubstance Abuse TreatmentClothingDentalHealthDomestic Violence ServicesHousing/Utility ServicesFood Programs

MEDICAL HISTORY AND INFORMATION:

Do you currently have a Primary Care Provider (i.e. doctor)?
YesNo

BACKGROUND INFORMATION

Do you have a probation or parole officer?
YesNo

If yes, please indicate their name and phone#:

Do you have any court cases or legal issues pending?
YesNo

If yes, please describe and provide date:

Please list criminal convictions below:

Describe Conviction:

FelonyMisdemeanorNo Convictions

Date:

County or Location:

-------------

Describe Conviction:

FelonyMisdemeanorNo Convictions

Date:

County or Location:

-------------

Describe Conviction:

FelonyMisdemeanorNo Convictions

Date:

County or Location:

-------------

Describe Conviction:

FelonyMisdemeanorNo Convictions

Date:

County or Location:

-------------

Describe Conviction:

FelonyMisdemeanorNo Convictions

Date:

County or Location:

-------------

Describe Conviction:

FelonyMisdemeanorNo Convictions

Date:

County or Location:

PLEASE SEND ALL REQUIRED DOCUMENTS TO:

Freestore Foodbank
1141 Central Parkway
Cincinnati, Ohio 45202

For more information, please call 513-482-7292.

DISCLAIMER AND SIGNATURE:

I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment in the program, I understand that false or misleading information in my application or during my interview may result in my release from the program. If this application leads to enrollment in the program, I understand that I may be asked to take and pass a physical exam, drug and alcohol screening, and/or have a doctor's release to participate.

Signature: (type your full name)

Date: