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Momentum Enrollment Application
Please complete the form below
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Are you a U.S. Veteran?
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If so, what branch did you serve in?
Did you receive honorable discharge?
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Work
What kinds of jobs are you looking for or interested in doing? Are you interested in an internship?
Where have you applied to work in the last 2 weeks?
Employment Restrictions
Is there anything physically or legally prohibiting you from employment?
Work History
When was the last time you worked? Where?
Additional Details
Do you have your driver’s license?
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If no, are you able to get your Driver’s License? If so, what do you have to do to get it?
Are you active in any programs? Treatment? Batterer’s Education? Church? Other Service Providers?
How did you hear about Momentum?
What drives you to be successful? What would cause you to make it six weeks?
Are you currently active in any mental health or substance abuse services?
Thank you! We will be in contact with you.
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Momentum Application Form
