SUPPORTIVE SERVICE APPLICANT STATEMENT

I HEREBY CERTIFY, UNDER PENALTY OF PERJURY THAT I received for

I attest that the information stated above is true and accurate. I understand that if the above information is misrepresented or incomplete, it may be grounds for immediate termination and/or penalties as specified by law.

Applicant’s Signature Date (MM/DD/YYYY)

Applicant’s Printed Name

Applicant’s Address

STAFF USE ONLY

The above applicant statement is being utilized for documentation of supportive services:

St. Louis County Workforce Development is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Missouri TTY users can call (800) 735-2966 or dial 7-1-1 for Relay Missouri.