APPLICATION FOR SUPPORT SERVICES

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CCMA PROGRAMS
- Priority Male Initiative >
  - Employer Partnership
  - INTERFAITH LEADERSHIP COALITION
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PRIORITY MALE EMPOWERMENT NETWORK
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APPLICATION FOR SUPPORT SERVICES

If you are a young man of color, 18-28 years of age, please complete the Application for Support Services form and you will be considered for related benefits, including free job readiness training, mentoring, computer equipment, and other services, under the Priority Male Initiative.

If additional information is needed, please call 404-935-5859.

* Indicates required field

Name *

First

Last

Phone Number *

Emergency contact *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Age *

Gender/Sex *

Female Male

Education *

Income *

Source *

Employment Status *

Special Needs: *

Training Employment Mentoring GED Other

Do you need a computer? *

Yes No

Do you need computer training? *

Yes No

Why do you need a computer? *

Are you interested in receiving a free laptop computer? *

Yes No

If so, are you willing to sign up for the free computer training? *

Yes No

Signature *

Submit

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About Us
CCMA PROGRAMS
- Priority Male Initiative >
  - Employer Partnership
  - INTERFAITH LEADERSHIP COALITION
TESTIMONIALS
PRIORITY MALE EMPOWERMENT NETWORK
APPLY FOR SERVICES
THE SAMUEL BRADY GREENE LEGACY FUND
Contact
Gallery
PROPEL VIRTUAL ACADEMY
- PROPEL VIRTUAL ACADEMY OVERVIEW
Sponsors & Partners
- How You Can Help
- Priority Newsletter >
Donate Now
Mailing List
Events