| Name: |
|
Phone Number:
|
|
| E-mail: |
|
| Have you been to our center before? |
Yes
No
|
| What kind of services are you seeking with us: |
|
| What kind of jobs are you seeking? |
|
| What have you been doing to find employment? |
|
| Have you received any vocational training? |
Yes
No
|
| Employment Status (Please check all that apply) |
Not Working
Attending School
Working Part Time
Working Full Time
Terminated
Department of Rehab
Quit
Company Closed
Laid Off
|
| What is your educational background? |
|
| Do you have any work limitations? |
Yes
No
|
| Have you received any of the following in the last 6 months? (Check all that apply) |
TANF
CalWORKs/GAIN
G.R.
VA
Ticket to Work
Food Stamps
SDI/SSI
UIB |
| |
|
