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American Job Center
Search
Make an Appointment
  • Plan Your Visit
  • Job Seekers
  • Employers
  • Programs
  • Contact Us
Menu
  • Plan Your Visit
  • Job Seekers
  • Employers
  • Programs
  • Contact Us

Intake Form

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MM slash DD slash YYYY
MM slash DD slash YYYY
Name
Address
MM slash DD slash YYYY
If exact date not known, please select a range below
Gender
Age Range
Is English your primary language?
Are you a Veteran?
Is your spouse a Veteran?
If yes, is your spouse currently serving in the armed forces?
Highest grade in school completed?
Trade/Vocational Training or Skills?
How many full years of service do you have with this company?
Average number of hours worked per week?
Have you worked in other occupations in the past 5 years?
What tools or equipment can you use?
Are you paid hourly or on salary?
If unsure, choose one of the following ranges.
Are you the primary wage earner for your household?
What is the maximum number of miles you are willing to commute one-way for employment?
Would you be willing to relocate for an employment opportunity?
Check all that apply.
What are your future employment plans?
Check all that apply.
Do you require any special work accommodations?
What type of computer skills do you possess?
Check all that apply.
What type of workshops are you interested in?
Check all that apply.
Would you like individual assistance with any of the following?
Check all that apply.
What training or education would you be interested in?
Check all that apply.
How satisfied are you with the information provided at the meeting today?

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1330 N Street, Suite A, Lincoln, Nebraska 68508

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