Trying to Make Change to Save Lives

One Life At A Time Submission Form



First Name

Last Name




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
Recent Grad

Have you been looking for work?(please check one)

If so, for how many months?

Are you currently receiving SSI, SSDI, or Unemployment benefits?

Have you been convicted of a felony?

Are you currently in recovery?(please check one)

If yes, for how long?

Are you currenlty eligible to work in the US?

How would you rate yourself?

Basic Computer Skills

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft PowerPoint

Microsoft Project

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

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