Intake Form

I certify that the information provided is true to the best of my knowledge. I understand that all information provided is subject to review and verification. I am also aware that I am subject to immediate termination if I am found ineligble after enrollment and may be prosecuted for fraud and/or perjury. I allow release of this information for verification purposes and understand that it will be used to determine eligibility. I also understand that if more than 45 days elapse from the date of application that a new application will be needed.