Program Application

 The information provided on this application will be held in confidence.  it will be used to find out if you qualify for additional employment services.  These services are provided without regard to race, age, sex, disability, religion, national origin, or political affiliation or belief.

Basic Information

Date: 

Name:

Home Address:

Mailing Address:

Phone Number:

Message Phone Number:

Birth Date:

Age:

Sex:

Race (check all that apply):

 African-American   American-Indian   Asian/Pacific Islander   Hispanic   White   Other

Education

Last School Attended: 

Last Grade Completed:

Do you have a high school diploma or GED? (Specify)

Did you take special education classes?

Have you taken any post high school classes? (if so, where and what)

Did you attend college?

Do you have a college degree? (If so, what type and major)

Employment

Company name and city:

Supervisor's Name: 

Start Date: 

End Date:

Wage (Indicate per hour, week, month, or year):

Hours per week:

Position title:

Duties:

Reason for Leaving:

Employment Continued

Company name and city:

Supervisor's Name: 

Start Date: 

End Date:

Wage (Indicate per hour, week, month, or year):

Hours per week:

Position title:

Duties:

Reason for Leaving:

Employment Continued

Company name and city:

Supervisor's Name: 

Start Date: 

End Date:

Wage (Indicate per hour, week, month, or year):

Hours per week:

Position title:

Duties:

Reason for Leaving:

Please list any type of special skilled you may have (i.e. computer, typing, forklift, etc.)

Indicate which of the following you receive if any.

TANF   Food Stamps   Medicaid   Day Care Assistance   SSI   Housing Authority Assistance   Transportation Assistance

Case workers name:

Do you receive unemployment benefits?

If yes, when will they end?

Do you know how getting a job will affect your assistance?

Have you ever been convicted of an offense?

If yes, was is a felony or misdemeanor?

What was the conviction for?

Are you on probation or parole?

Who is your probation/parole office?

I promise that the above information is true.  I understand that if I am eligible for and enrolled in additional services, I am making a commitment to complete activities and get a job.

Your Signature:

Date:

Supplemental Program Application

How long have you lived at your current address?

Are you registered with selective services?

Are you a veteran? if yes, which branch?

If you do not receive unemployment, are you await a deputy decision?

Roughly, what is your household income?

How many people live in your household?

How many dependents do you claim?

List all training, certificates, occupational licenses you have completed (include title, institution, date completed)

List below the jobs you have applied for in the past seven days (include position applied for and company)

In detail, describe your career aspirations.  Where do you see yourself in five years with regards to employment?  What do you need to do to get there? (Example:  I would like to be a truck driver, I need my GED and CDL.)  PLEASE DO NOT SAY YOU WANT A JOB THAT WILL MAKE YOU MONEY! Of course you do, we all do. BE SPECIFIC!