GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 
Department of Human Services 
               
 Division of Senior Citizen Affairs- Information and Referral Services 
 
SENIOR IDENTIFICATION APPLICATION 
 
 
NAME   ________________________________________________________________________________________ 
                Last                                                  First                                                            Initial 
 
SOCIAL SECURITY #________________ DATE OF BIRTH______________ PLACE OF BIRTH ______________ 
 
ADDRESS:     (PHYSICAL) _______________________________________________________________________ 
 
 
 
 
         (MAILING)   _______________________________________________________________________ 
 
TELEPHONE NUMBER: (HOME) _____________ (WORK) _______________      (CELL) _______________ 
 
CITIZENSHIP STATUS:    A.   Alien__ B.   U.S.  Citizen__ C.  Resident Alien (Green Card) ___ 
ETHNICITY:  A. Black____    B. Caucasian _____   C. Hispanic _____     D. Other _____ 
MARTIAL STATUS:   Married___ Single___ Divorced___ Widowed___ Separated ____ 
NAME OF SPOUSE / CONTACT PERSON: ___________________________________________ 
(H) _______________________ (W) ________________________ (CELL) __________________________ 
 
ADDRESS: _____________________________________________________________________________________ 
 
EMPLOYMENT STATUS: 
 
A. Unemployed ___ B. Part-time employment___ C. Retired____       D. Full-time employment___  
E. Are you interested in Employment?   Yes____   No _____ 
Name of Employer ____________________________________________________ 
 
Address ____________________________________________________________ Phone __________________ 
 
 
What is the state of your health?     Fair ___   Good ___ Excellent ____ Average___ Poor___ 
 
Do you have any ailments? ________________________________________________________________________ 
Do you have difficulties taking care of yourself?   Yes ___     No ___ 
 
If yes, what are those difficulties? __________________________________________________________________ 
 
 
Please list medications that you are currently taking? ______________________________________________ 
 
_________________________________________________________________________________________ 
 
What are your food/drug allergies? _______________________________________________________________ 
 
SERVICES RECEIVED/ NEEDED: 
 
Mental Health Services ___ Home Delivered Meals___ Homemaker Services___ 
Home Health Care ___ Income Maintenance ___ Adult Protective Services___ Housing ___ 
Educational (U. V .I.) ___ Medical Assistance ____ Social Security ___ Food Stamps ___