One Life At A Time Submission Form

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 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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