Job Application Form - Virginia Workforce Network

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Contact Information:
Name (First, Middle, Last) ______________________________________________________________________
Address ____________________________________________________________________________________
City or County of Residence _____________________
Phone (daytime, evening, mobile) __________________Email address (Optional)_______________________
Best way to contact you (circle one) Phone:
Daytime
Evening
Mobile
Email
Identifier Information:
Last 4 digits of Social Security Number _________________ Date of Birth _____________________
Are you? (circle one)
Male
Female
Are you a U.S. Citizen? (circle one)
Yes
No
Are you Eligible to Work in the U.S.? (circle one)
Yes
No
What is your primary language? (optional)__________________________________________
Are you registered with selective service? (circle one)
Yes
No
Not applicable
Have you served in the U.S. Military? (circle one)
Yes
No
If yes, dates, branch of service _______________________________________________
Are you eligible for military education? (optional) (circle one)
Yes
No
Employment/Education:
Are you currently employed? (circle one) Yes
No
Are you currently a student? (circle one) Yes
No
Highest grade level completed? Please specify _____________
Are you a High School graduate? (circle one) Yes
No
Do you have a GED? (circle one)
Yes
No
Other Information:
Household size? (total number living in household?) (optional)______________
Household Annual Income (optional)______________
Do you have reliable transportation to get to service providers, training, employment? (circle one)
Yes
No
Answering the following questions, may qualify you for other benefits or services. Your responses could help staff
provided better job search assistance, training and referrals. This information will not be provided to employers.
Do you have a disability? (circle)
Yes
No
What type of disability?
(Check all that make it hard for you to get a job, keep a job or participate in training).
_____ Physical (examples: mobility, medical or health condition, such as diabetes or heart condition)
_____Mental (examples: anxiety or depression)
_____Learning (examples: difficulty with reading, writing, math or staying on task)
_____Sensory (examples: vision or hearing problems
_____Other (please specify) __________
_____I would like to speak with someone privately regarding this question
I’m interested in:
___ looking for a job.
___ a GED
___ applying for unemployment benefits or asking a
___ getting help with reading skills
question about my claim
___ Help with information about
___ Employment, Educational and/or training programs
child care
and services for:
health care
Adults
Transportation
Adults 55+
emergency bill payments
Youth (14-24)
food stamps
People who have been laid off
temporary assistance for needy families
People with disabilities (physical, learning or
fuel assistance/home weatherization
psychological)
other: _____________
People in drug or alcohol recovery programs
___English for Speakers of Other Languages (ESOL)
Ex- offenders
___ Workshop, Class or appointment
Veterans
(please specify)
___ Housing Assistance
______________________________________
The Workforce Center and its partners are equal opportunity employers/programs.
Auxiliary aids and services are available upon request to individuals with disabilities

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