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About Us
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History
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Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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Algeria
American Samoa
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Austria
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Chile
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Congo, Democratic Republic of the
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Dominican Republic
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El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
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Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
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Maldives
Mali
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Nigeria
Niue
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Panama
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Pitcairn
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Portugal
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Saint Helena, Ascension and Tristan da Cunha
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Samoa
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Taiwan
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Tanzania, the United Republic of
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Tonga
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US Minor Outlying Islands
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Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
County
Home Phone
Cell Phone
Personal Email
Current or Most Recent Job Title
Last Day of Work
MM slash DD slash YYYY
If exact date not known, please select a range below
Within 30 Days
Within 60 Days
Within 90 Days
Within 120 Days
Within 180 Days
More than 180 days
Unknown
Gender
Female
Male
Other
Age Range
18 -21
22 – 35
36 – 49
50 – 64
65+
Is English your primary language?
Yes
No
If no, what is your primary language?
Are you a Veteran?
Yes
No
Is your spouse a Veteran?
Yes
No
Not Married
Surviving Spouse
If yes, is your spouse currently serving in the armed forces?
Yes
No
Highest grade in school completed?
Did not complete high school
High school graduate/GED
Some college, no degree
Associate Degree
Undergraduate Degree
Postgraduate Degree
Trade/Vocational Training or Skills?
No Trade/Vocational Training
Some Trade/Technical School, no certificate
Trade/Vocational Certificate or Licensure
What training/certifications do you have?
How many full years of service do you have with this company?
Less than 1 year
1 to 4 years
5 to 9 years
10 to 14 years
15 to 19 years
20 to 24 years
25 to 29 years
30 or more years
Average number of hours worked per week?
Less than 20 hours
20 – 31 hours
32 – 34 hours
35 – 40 hours
More than 40 hours
Altogether, including other employers, how many years have you worked in this type of occupation?
Have you worked in other occupations in the past 5 years?
Yes
No
If yes, please list:
What tools or equipment can you use?
Add
Remove
What is your rate of pay?
Are you paid hourly or on salary?
Hourly
Salary
If unsure, choose one of the following ranges.
Under $9.25/Under $19,240
$9.25-11.49/$19,240-$23,919
$11.50-$14.49/$23,920-$30,159
$14.50-$18.24/$30,160-$37,959
$18.25-$22.74/$37,960-$47,319
$22.75-$28.74/$47,320-$59,799
$28.75-$35.99/$59,800-$74,879
$36.00-$45.24/$74,880-$94,119
$45.25 and over/$94,120 and over
Are you the primary wage earner for your household?
Yes
No
How many Children do you have living at home?
What is the maximum number of miles you are willing to commute one-way for employment?
10 or less
20
30
40
50 or more
Would you be willing to relocate for an employment opportunity?
Check all that apply.
Relocate within the State.
Relocate to neighboring states.
Relocate nationwide.
What are your future employment plans?
Check all that apply.
Seek full-time employment immediately (same job type)
Seek full-time employment immediately (new job type)
Seek part-time employment immediately (same job type)
Seek part-time employment immediately (new job type)
Already have a job lined up
Attend school/training
Obtain additional certification
Start my own business
Retirement/leaving the workforce
Undecided
Other
If Other, Please specify:
Do you require any special work accommodations?
Yes
No
What type of computer skills do you possess?
Check all that apply.
Access the internet
Send and receive email
Create or use databases
Write letters or other documents using word processing
Do financial record keeping or bookwork using spreadsheets
Able to use presentation software
None of the things listed
Other
If Other, please specify:
What type of workshops are you interested in?
Check all that apply.
Job Search
Resume Writing
Interviewing
Basic Computer Skills (email, internet)
Intermediate Computer (MS Word, Excel)
Advanced Computer Skills
Other
If Other, please specify:
Would you like individual assistance with any of the following?
Check all that apply.
Finding out what jobs are available
Understand how my skills & experience relate to new jobs
Deciding what jobs I can do
Learning how to find a new job
Developing a resume
Filling out job applications
Dealing with my loss of employment
Rehiring concerns (i.e., age, criminal history, disabilities, etc.)
Budgeting & paying my bills without a job
Helping my family through this current situation
Deciding which school would be best for me
Tuition & books
Paying for child care while I go to school
Transportation expenses to & from school
Paying moving expenses
Other
If Other, please specify
What training or education would you be interested in?
Check all that apply.
Reading skills training
Math skills training
Basic computer skills training
Finishing/Obtaining a TradeNocational Certificate or Licensure
Finishing/Obtaining a GED/High School Equivalency
Finishing/Obtaining an Associate Degree
Finishing/Obtaining an Undergraduate Degree
Finishing/Obtaining a Graduate Degree
Unsure
Other
If Other, please specify:
If interested in occupational training, what is your field of interest?
How satisfied are you with the information provided at the meeting today?
Very satisfied
Satisfied
Not very satisfied
Please provide us with any additional comments regarding how we could improve the meeting:
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