Participant App for Expansion of Pilot

Attachment A–Sample Enrollment Survey

Applicant Data Collected

• Name: First, Middle, Last

• Date of Birth

• Gender

• Height

• Hair Color

• Place of Birth

• Home Address (current and past)

• City/State/Zip

• Other names used including Alias or Nicknames

• Email address

• Telephone number (home)

• Telephone number (cell phone)

Potential Enrollment Data to be Collected

• Social Security Number

• Driver’s License: Number, State Issued, Expiration Date

• Ethnicity

• US Citizen (Y/N)

• If Not US Citizen:

  • Alien Registration Number: Passport Issued by, Passport Number

INS Review: Work Permit Valid Until date, Any prior deportations (Y/N/comments)