Auxiliary aids and services are available upon request to individuals with disabilities. Once you complete and submit the form you will receive an email copy for your records. You must have JavaScript enabled to use this form. Customer Data Last Name First Name Middle Initial Date of Birth Gender SelectFemaleMalePrefer Not to Street Address City/Town State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code County Home Phone Cell Phone Email How do you prefer to be contacted? - Select -EmailCell PhoneHome PhoneU.S. Mail Are you a US Citizen? Yes No If no, are you authorized to work in the US? Yes No If yes, Alien Registration Number Ethnicity/Race Note: The Ethnicity and Race questions are voluntary. Information is confidential and will only be used for record keeping and affirmative action requirements. You will not be penalized if you do not want to answer. Ethnicity Race (Check all that apply) Hispanic or Latino Not Hispanic or Latino White Black or African American American Indian or Alaska Native Asian Native, Hawaiian or Other Pacific Islander Education Education Grade (select highest level completed) - Select -None1st2nd3rd4th5th6th7th8th9th10th11th12thHigh School DiplomaHS EquivalencyIEP Diploma1 year College2 years College3 years College4 years College If you have received an education from outside the United States, please indicate here If college, check all that apply Some college Associate 's Degree Bachelor's Degree Master's Degree Doctoral Degree Vocational Degree/Certificate Are you attending a secondary, post-secondary, vocational, technical or academic school full-time? Yes No If you are between terms, do you intend to return to school? Yes No Military Veterans and "eligible spouses" receive priority of service. Did you serve in the United States Armed Forces? Yes No Are you an eligible spouse of a veteran? Yes No If "Yes" what US military branch? Dates of Active Service From Dates of Active Service To If you're a male born after Dec 31, 1959, are you registered with the US Military Selective Service? Yes No Employment Are you currently employed? Yes No If No, how many weeks have you been out of work? If Yes, are you employed Full time Part time How many hours do you work per week? Employment Preferences Work Week Check your work preferences Full time (30 hours per week or more) Part time (Less than 30 hours per week) Any Duration (length of employment) Regular (More than 150 days) Temporary (3 days or fewer) Regular or Temporary (4-150 days) Minimum acceptable wage required $ per Hour Day Week Month Year Other Date you are available to work Which shifts are you willing to work? Check all that apply First (shift that begins in the morning) Second (shift that begins in the afternoon/early evening) Third (shift that begins at night) Split Rotating Any Are you a migrant or seasonal farm worker? Yes No Employment Objective Employment objective/Type of work you are seeking Job Title Job Title List most recent occupation(s)/job(s) Job Title Experience in this Job: Years Experience in this Job: Months Job Title Experience in this Job: Years Experience in this Job: Months Acceptable Job Locations I am willing to work within the following zip code, county or state (check the number of miles and write the zip code) Number of Miles 10 25 50 100 from... Zip Code Location County Location State Location Work History Most recent job held first Job Title Employer Job Address Job City Job State SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Job Type SelectFull TimePart TimeInternshipJob ShadowingMentoringMilitaryVolunteerLife Experience Start Date End Date Supervisor Supervisor Phone Number Wage $ Paid SelectWeeklyMonthlyYearlyOtherSal & COPer DiemContractComm Hours per Week Reason for Leaving Job Duties Additional Work History Next most recent job held Job Title Employer Job Address Job City Job State SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Job Type SelectFull TimePart TimeInternshipJob ShadowingMentoringMilitaryVolunteerLife Experience Start Date End Date Supervisor Supervisor Phone Number Wage $ Paid SelectWeeklyMonthlyYearlyOtherSal & COPer DiemContractComm Hours per Week Reason for Leaving Job Duties Driver's License Do you have a driver's license? Yes No Issuing State What type of license do you have? SelectClass A (tractor trailer)Class B (truck/bus)Class C (light truck/commercial)Class Cn (non CDL)Class D (operators)Class E (taxi)Class M (motorcycle) Endorsements SelectPassenger TransportHazardous MaterialsTank VehiclesMotorcycleSchool busDoubles/TriplesTank HazardAir Brakes Do you need public transportation to get to a job? Yes No Do you have reliable transportation to and from work? Yes No Certificates/Licenses Do you have an occupational certificate or license? Yes No Certificate/License Issuing organization or locality Issue date (month/year) Licensing State Licensing Country Additional Certificate or License Do you have an occupational certificate or license? Yes No Certificate/License Issuing organization or locality Issue date (month/year) Licensing State Licensing Country Additional Certificate or License Do you have an occupational certificate or license? Yes No Certificate/License Issuing organization or locality Issue date (month/year) Licensing State Licensing Country Schools Do you have a college degree, diploma or educational certificate? Yes No Course of study Degree Date completed Issuing institution Institution's State Institution's Country Course of study Degree Date completed Issuing institution Institution's State Institution's Country Job Skills and Qualifications List at least one. Include skills and abilities that you used in your job(s), volunteer work, personal experiences, or that you have acquired through school or training. Examples: laboratory techniques, carpentry, welding, ability to read blueprints, typing, and computer skills such as word processing software, programming languages, or computer assisted design. Also, include languages in which you are fluent. List qualities or accomplishments related to your employment goal List any honors you have received or outside activities you participate in I certify that the information given on this document is true and accurate to the best of my knowledge. Signature Today's Date
