Please provide some basic information about
yourself
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First Name
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| Last Name |
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Home Phone Number
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| Cell Phone Number |
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Email Address (this is very important since many of our communications
will be emailed to you)
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Confirm e-mail
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Street Address
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| City |
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| State |
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County of Residence
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County of Residence
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County of Residence
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| Zip Code |
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Please tell us about your current employment
and/or training situation
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1) Are you currently employed?
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Yes
No |
2) If you are employed, what is your employment status:
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Full-time with an employer
Part-time with an employer
Self-employed
Employed now but have received a notice of an upcoming layoff or closure
Not Applicable
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3) If you are not employed, what happened on your last job?
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Voluntarily resigned
Fired
Laid off
Company closed
Was self-employed but economic or other conditions forced me out of business
Not Applicable
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| 4) Are you unemployed and previously dependent on the income of
your spouse who is no longer providing that income due to death
or divorce/separation? |
Yes
No |
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If you have already been laid off from a job
OR you have received notice of an upcoming layoff or closure OR
your employer’s business has already closed, please tell us
about that layoff or closure.
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5) What is the company’s name?
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| 6) What was your last date of employment or what will be your
last date of employment according to the notice you received? |
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Please tell us what your employment or training-related
needs are right now
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7) What is your primary interest now?
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My primary need is to re-enter full-time employment or find a better job as quickly
My primary need is to re-enter employment but I would also like to re-train at the same time
My primary interest is in re-training
I am not sure what to do next and need help deciding
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8) If your primary interest is to go directly back to work or
get a better job than you currently have, what general type of work
are you looking for?
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Direct healthcare
Supply chain including warehouse or distribution
Customer service related
Office or clerical
Manufacturing or production
Management or administration
Information technology
Education
government employment
Armed forces
Something else
Need help deciding
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9) If you have a specific job or occupation you are trying to
obtain or enter, what is it?
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10) What type of work do you have the most actual experience doing?
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Direct healthcare
Supply chain including warehouse or distribution
Customer service related
Office or clerical
Manufacturing or production
Management or administration
Information technology
Education
Government employment
Armed forces
Something else
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11) If your primary interest is to return to school or be retrained
in a new occupation, what general area would that be in?
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Direct healthcare
Supply chain including warehouse or distribution
Customer service related
Office or clerical
Manufacturing or production
Management or administration
Information technology
Education
Government employment
Armed forces
Something else
Need help deciding
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12) If you have a specific job or occupation you are seeking training
for, what is it?
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| 13) Please provide any additional information or comments that
can help us to better provide assistance to you. |
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Your Work History
By providing additional information about your work history, education,
and existing credentials, we can more quickly and accurately match
your skill set to opportunities that exist now or that become available
in the future.
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| Current or most recent employer |
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| Job title |
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| Hourly Wage or Annual Salary |
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| Date you started work |
Start Month
Start Year
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| Last date of work - Leave blank if currently
employed |
End Month
End Year
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| Previous employer |
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| Job title |
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| Hourly Wage or Annual Salary |
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| Date you started work |
Start Month
Start Year
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| Last date of work |
End Month
End Year
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| Earlier employer |
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| Job title |
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| Hourly Wage or Annual Salary |
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| Date you started work |
Start Month
Start Year
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| Last date of work |
End Month
End Year
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Your education
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14) What is your highest education level?
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Did not complete high school
Received a high school diploma, GED or other equivalent
Have some post-high school education
Have an associate's degree
Have a bachelor's degree
Have a master's or other advanced degree
Have a technical certificate or diploma
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15) If you received a technical certificate, associate’s
degree, bachelor’s degree, master’s or higher degree,
what was it in?
If you have more than one, enter them all and
separate them with commas. An example would be: Information Technology,
A+, MCSA |
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| Your existing skills |
16) Please enter key words that describe any existing skills
that you have. If you enter multiple skills,
separate them with commas. We will be able to search this
field to match you to jobs or other opportunities that may be
available.
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Here are some examples: data entry, Excel, customer
service, nursing, welding, Microsoft Office, helpdesk, supply chain,
clerical, management, human resources, computer network.
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If the information above is correct, click on the
"Submit My Application" button below. The next
screen will have a User ID and Password that you can use to log-in
in the future. You will also see the what is available for
your next steps.
Please click button only one
time
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