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Project Profectus Application to Participate in the Advancement Communities Program


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


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 . 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