Project Clean Slate

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: 020612063552
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
	Total fees: $ (ex: 254.75)
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 Agreement: 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. PCS is always striving to learn how well we are doing and to improve our services. For the purposes of evaluating the success of our program we would like to access DMV driver’s license information and child support payments (if applicable.) Please check the box if you agree to allow PCS access to your DMV and child support records. Understood and agreed Yes No (required) Enrollee agrees to allow PCS to use their photo, likeness or profile for marketing purposes Yes No