Trying to Make Change to Save Lives

One Life At A Time Submission Form

 

Date

First Name

Last Name

Address

City

State

Zip Code

Your Email

Home Phone Number

Cell Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Email

How did you hear about us?

Are you currently receiving Unemployment Benefits?

Are you currently receiving SSI or SSDI?

Have you been convicted of a felony?

Are you currently in recovery? (please check one)

If yes, what is your sobriety date?

Are you taking an active role in your recovery? If so, what does recovery look like to you?

Are you currently on MAT (Medically Assisted Treatment)? (please check one)

Employment status? (please check one)
Job Changer
Unemployed
Recent Grad

Do you have transportation? (please check one)

Are you looking for full time or part time work? (please check one)
Full Time Part Time

What type of job are you looking for?

What industry do you want to work in?

Brief description of your last job?

What annual or hourly salary range are you looking for?
K/yr or /hour

Highest Completed Grade Level?

Highest Degree Obtained?

List other certifications or training you have:

Rate yourself in the following technical subjects:

Basic Computer Skills

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft PowerPoint

Upload your resume (.pdf, .doc, or .docx, maximum file size 2MB)

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