Leap Application


Name:

Address:

Phone:

Gender:

Race:

Family

Martial Status:

Birth date:

Children under 18?

Number of children under 18:

Who is their legal guardian:

Child Info:

Medical

Does anyone in your family have depression, addiction, anxiety, or other issues?

If they said yes, here is the info:

Education

Highest Grade Completed:

Do you have a:

Last school attended:

When:

Benefits (how much from)

Social Security:

Workers Comp:

Social Security Disability:

Food Stamps:

Temporary Cash Allowance:

Housing Assistance:

VA:

Other:

Legal

How many times have you been arrested:

Arrest info:

Employment

Last employer:

Wage:

Start Date:

End Date:

Type of work:

Position:

Reason for leaving:

Identification Information

The ID’s the applicant has:

Emergency Contact

Name:

Address:

Phone:

Leave this empty:

Horizon Goodwill Industries https://horizongoodwill.org
Signature Certificate
Document name: Leap Application
Unique Document ID: d6e94b0b23c3be8ff3c0cd6cb176d8dcf99c830a
Timestamp Audit
2017-04-17 14:54:15 EDTLeap Application Uploaded by John McCain - dcarbaugh@goodwill-hgi.org IP 24.89.1.215