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Youth Hotline: (404) 687-3822

320 Church Street Phone: (404) 687-3400
Decatur, Georgia 30030 Fax: (404) 687-3443

YOUTH SERVICES APPLICATION & CUSTOMER INFORMATION

Please print your responses to the following questions. Complete a separate form for each youth applicant.
APPLICATION Date: 04/24/2009
__________________
Applicant Name Social Security Number

DEANTHONY M 255 - 81 -
First M.I. Last DENNIS 2006
Birth Date Age Gender
08 / 26 / 1991
17 … Male … Female
Guardian's Name Guardian's Work Number:

NANCY THOMAS (770 ) 819-2036 /fax ( )

Home Phone: Cell Phone Email Address

(770 ) 323-2380 (678 ) 485-9094 deanthony.dennis@yahoo.com

Mailing Address: City State Zip Code

6255 marbut farms terrace lithonia ga 30058

Home Address City State Zip Code

6255 marbut farms terrace lithonia ga 30058

Someone with whom we can leave a message that does not live with you.

Name: MS. SETTLES Telephone: ( 678 ) 732-6372

Are you a US Citizen If you are not a US Citizen, please complete:

… Yes … No Alien Card #: ____________________________________ Exp. Date_____/_____/____

Race (Check all that apply)
… White … Black … Asian … Pacific Islander … Native American … Hispanic
ELIGIBILITY INFORMATION
Does anyone in your household receive TANF and/or food stamps? … Yes … No
Do you have a disability or an Individual Education Plan (IEP)? … Yes … No
Have you been arrested or in trouble with law enforcement or juvenile court? … Yes … No
Are you behind one or more grade levels in school? … Yes … No
Do you have a misdemeanor or felony conviction? … Yes … No
Are you a school dropout? Withdrawal Date:_____________________ … Yes … No
Are you a runaway youth and/or homeless? … Yes … No
Are you pregnant or parenting a child? … Yes … No
Are you currently in or have ever been in foster care? … Yes … No
Do you need assistance in completing an educational program or securing and retaining a job? … Yes … No
I am a male registered with the Selective Service (males only, born on or after 1/1/60.) … Yes … No
Number in family (including applicant):3 ______________
Average monthly income for the past six (6) months: $0____________________/month
(Do not include unemployment compensation, child support payments, old age and survivors insurance benefits received under
the Social Security Act, or TANF payments.)

FAMIY INCOME (last six (6) months)

Previous 6-Month Income
Family Member Source of Income Amount (to nearest dollar)
NANCY THOMAS NA
BRIANNA WHITE NA
DEANTHONY DENNIS NA

Total 6-month income for household:

1 WIA - 101
Equal Opportunity Employer/Program
Auxiliary Aids & Services Available to Individuals with Disabilities revised 04/01/2009
 EDUCATION & WORK HISTORY
Highest grade level completed.12TH
___________
School currently attending? LITHONIA HIGH SCHOOL
_______________________________________________
Anticipated date of HS graduation and/or GED attainment? _________________________________
MAY 23 2009
Secondary Education completed. (if applicable): … High School Diploma … GED
Post Secondary Education attended/completed. (if applicable): … Technical School … AA … BA/BS Date: ____

I am authorized to work in the United States. … Yes … No

Have you ever been employed? … Yes … No
If yes, list all previous employers in the following sections:
Name of Employer Type of Business
KENLEY'S CATERING
Address City State Zip code
75 PIEDMONT AVE. ATLANTA GA 30058
Dates Employed From (month/year -to (month/year) Title
08-1-2007, 11-09
Name and Title of Supervisor Telephone Number
KENLEY ( 404 ) 523-0850
May we Contact Type of Employment
YES … Part Time … Full Time
Brief description of duties:
CASHIER/SERVER
Reason for leaving: Last Salary:
SEASONAL $ 6.50 WEEK
Per___________

Name of Employer Type of Business

Address City State Zip code

Dates Employed From (month/year -to (month/year) Title

Name and Title of Supervisor Telephone Number

( )
May we Contact Type of Employment
… Part Time … Full Time
Brief description of duties:

Reason for leaving: Last Salary:

$ Per___________

CERTIFICATION AND ACKNOWLEDGEMENT

(Please read the following statement carefully)

I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I also agree that
falsified information or significant omissions may disqualify me from further consideration for WIA program activities and may be
considered justification for dismissal if discovered at a later date.
I further understand that if information presented is determined to be false or contain omissions, I will be held responsible for
repayment of any funds paid to me or for services on my behalf.
Finally, I recognize that an application and eligibility determination are initial steps and do not guarantee program participation.
DEANTHONY DENNIS
_____________________________________ 4/23/09
_____________________
Applicant Signature Date
NANCY THOMAS
_____________________________________ 4/23/09
_____________________
Parent Signature (required if applicant is not 18 years or older) Date

2 WIA - 101
Equal Opportunity Employer/Program
Auxiliary Aids & Services Available to Individuals with Disabilities revised 04/01/2009