Central Connections – Self-Certification

Identifying Information
Applicant’s Last Name*
Applicant’s First Name*
Applicant’s MI*
Address*
City*
State*
Zip Code*
County of Residence*
Participant ID*
Application Date*
Certification
I hereby certify under penalty of law, that the following information is true.
I attest that the information stated above is true and accurate, and understand that the above information, if misrepresented, or incomplete, may be grounds for immediate termination and/or penalties as specified by law.
Applicant’s Signature*
Date*
MM slash DD slash YYYY
Applicant’s phone number*
Signature of parent or guardian (Required if applicant is under 18 years of age)
Date
The above Self-Certification is being utilized for verification of the following eligibility criteria:

Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program.