State of Oregon
Multnomah County Sheriff
Multnomah County District Attorney
City of Portland, Oregon
Portland Police Bureau
African American Chamber of Commerce of Oregon
Project Clean Slate Information Form - Multnomah County
Please note: that this is NOT the application form, only a pre-application.
This form does not guarantee that you will be accepted into Project Clean Slate.
It is your obligation to keep us informed by email or fax of any address or phone number changes.
Reference Number: 112308033622
Birthday:   (ex: MM/DD/YYYY)    AGE:
SSN: Last 4 digits only!
Sex:     Race:
First name: M.I.:
Last name:
Address: Apt:
City / State: Zip:
County:
 
  • You must provide at lease one unblocked
       phone number in case we need to call you.
    • Home phone:     Extension:
    Work phone:     Extension:
    Cell phone:  Eve. phone:
    Email address:
    Other names you are or were known by:
    1.
    2.
    3.
    4.

    Assistance is needed in the following areas: (check all that apply)
    Yes No: Suspended Drivers License - NO past due fines or fees
    Yes No: Suspended Drivers License - WITH past due fines or fees
    Yes No: Minor Criminal Convictions (Currently Multnomah County Only)
    Yes No: Do you have past due child support?
    If so, approximately how much?
    Yes No: Do you have past due spousal support?
    If so, approximately how much?

    Please answer the following questions...
    Employment status:
    Job description:
    Highest grade completed:
    Your household:
    		Adults: Minors:
    Employed people in your household:

    How do you pay your bills:

    		Cash Check Money order Credit Card Online Payment
    Your annual income: Under $10,000 $10,000 to $30,000
    30,000 to $50,000 Over $50,000
    Living situation: Own or Buying Renter Leasing
    Living with Friends or Relatives Homeless
    Yes No: Did you file your income tax return in the past 24 months?
    Yes No: Do you have current auto insurance coverage in your name?
    Yes No: Do you have current health insurance coverage?
    Yes No: Do you speak foreign language?
    If so, which one:

    Have you received any type of public or government assistance in the past 6 months?
    Yes No: Unemployment
    Yes No: Social security
    Yes No: Food stamps
    Yes No: Public assistance
    Yes No: Transportation assistance
    Yes No: Worker's compensation
    Yes No:

    		Loans from Friends/ Family

    Describe any and all voluntary public service or human service work that you have performed over the past 3 years:

    Are you interested and seriously ready to be referred to social service agencies that
    can assist you in enhancing and improving your life? Yes No Unsure
    Preferred Job 1:
    Preferred Job 2:
    My Goals over 
    the next 2 years:
    Other comments 
    or information:
    Confidentiality: I understand and agree that...
  • This information will be held in the strictest confidence by Project Clean Slate
  • This information will only be used for statistical and project reporting involved with Project Clean Slate
  • Project Clean Slate and affiliates may need to contact me by phone or email regarding this information
  • I must notify Project Clean Slate of address or phone changes immediately to keep my data current

    Understood and agreed Yes No   (required)
    Enrollee agrees to allow PCS to use their photo, likeness or profile for marketing purposes Yes No