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Project Profectus Application to Participate in the Advancement Communities Program

ADVACEMENT
COMMUNITIES

Referral From ______________; Place of Employment


______________

Is this a not-profit institution? Yes_____ or No_____

In a few sentences, please describe why are you referring


this applicant?

_____________________________________________________________

Applicant: First and Last Name _______________


________________

Date of Birth_____________; E-mail


Address_________________

Are you a U.S. citizen or permanent resident? Yes______


or No_______

How Old Are You? ______; What County do you Reside


In? _________

Guidelines are 138% of the federal poverty line, do you


make less than $16,643 a year as an individual?
Yes_____ or No________
Please also turn in at least one single proof of income with this sheet (I,e W2, tax returns,
last paycheck etc.) Information can be scanned and sent to the secure e-mail address
malcolmheard@projectprofectus.com . To send by USPS mail please contact Malcolm at
(310) 995-5322 for further instructions. All information is confidential and it is advised
the person making the referral sign off first. The applicant will be contacted via e-mail