Inquiry of MVAC Services Form

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Inquiry of MVAC Services Form

You may complete an application to be one of our volunteers by filling out the form below. Fill out as much information as possible. Fields marked with a red asterisk (*) are required.

Contact Information

Please leave this field empty.

 Own Rent Other

Sources of Income

 Salary or Wages Alimony/Child Support Social Security Self Employment Retirement/Pension MSA Other/Interest No Income General Assistance Reemployment Comp. TANF (AFDC, MFIP) SSI Food Stamps Housing Medical Aid/Asst. Veterans Benefits

Household Type

 Farm Migrant Seasonal Farm Worker

 Yes No

 Single Parent/Female Single Parent/Male Adults with children Single Person Adults only Other

Program(s) or Service(s) of Interest?

 Energy Assistance Weatherization Rental Assistance Jobs for Seniors Head Start Energy Conservation Home Improvement Loans Jobs and Training Transportation Other

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Questions or Comments

Data Privacy Rights of Applicants for MVAC Programs

Under current Federal and State legislation your right to privacy is protected. MVAC is asking you to supply us with private information concerning you, your family, and household. By Law you do not have to provide this information. MVAC needs information about you to determine if you can get help from any program. Without information about your household, MVAC may not be able to help you and the help may be late or less than what you may be eligible to receive. The purpose for this information is to inform you of eligibility for all programs at MVAC. MVAC may use information to research, plan, and evaluate programs. Information is used in determining compliance with Federal and State regulation's. MVAC will use this information to make statistical and demographic reports to different agencies and funding sources. Never will information that identifies you or any member of your household be revealed unless you give your written permission. MVAC will also use this information to develop a mailing list. MVAC will use the mailing list to update you on the programs and program changes. At no time will the mailing list be revealed to anyone outside MVAC. To assure that you are being served properly only MVAC Staff whose jobs require the information will have access to it.

MVAC may share this information with state and local welfare agencies, community based organizations, local and state public and private human service agencies, Department of Education, the United States Department of Labor, the United States Department of Health and Human Services and state and local educational programs, as allowed by law.

This Agency will keep this information for seven years from the last date updated with you or until program audits are complete. You have the right to review your records at any time to request changes.