Project Second Chance 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 Second Chance.
It is your obligation to keep us informed by email or fax of any address or phone number changes.
Reference Number: 092217114556
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:
Email address:



 
  • 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:
    Cell phone carrier:
    Text messaging: Does your cell phone have text messaging so we can
    notify you of your Project Second Chance appointment times?



    Alternate Contact Information:
    Alternate email address:
    Alternate phone:



    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 Second Chance.


    • This information will only be used for statistical and project reporting involved with Project Second Chance.


    • Project Second Chance and affiliates may need to contact me by phone or email regarding this information.


    • I must notify Project Second Chance of address or phone changes immediately to keep my data current.


    • PSC 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 PSC access to your DMV and child support records.
      Understood and agreed Yes No   (required)


      Enrollee agrees to allow PSC to use their photo,
      likeness or profile for marketing purposes Yes No