Date
First Name
Last Name
Address
City
State
Zip Code
Your Email
Phone Number
Cell Number
Emergency Contact Name
Preferred method of contact for emergency contact:
Emergency Contact Phone Number
Emergency Contact cell Number
Emergency Contact Email
How did you hear about us?
What type of jobs are you looking for?
What industry do you want to work in?
Full Time Part Time
Brief description of your last job?
What salary range are you looking for? K/yr or /hour
Completed Grade Level?
Highest degree completed
Other types of training you have (vocational, on-the job, military training or other formal training/education)?
Employment status? (please check one) Job Changer Unemployed Recent Grad
Have you been looking for work?(please check one) YesNo
If so, for how many months?
Are you currently receiving SSI, SSDI, or Unemployment benefits? YesNo
Have you been convicted of a felony? YesNo
Are you currently in recovery?(please check one) YesNo
If yes, for how long?
Are you currenlty eligible to work in the US? YesNo
How would you rate yourself?
Basic Computer Skills No SkillGoodIntermediateExcellent
Microsoft Word No SkillGoodIntermediateExcellent
Microsoft Excel No SkillGoodIntermediateExcellent
Microsoft Outlook No SkillGoodIntermediateExcellent
Microsoft PowerPoint No SkillGoodIntermediateExcellent
Microsoft Project No SkillGoodIntermediateExcellent
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