Application For Employment Form
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1
2GENERAL INFORMATION
LEGAL NAME: First:
Middle:
Last:
DATE:
/ /
ADDRESS:
APT/UNIT #
CITY:
STATE:
ZIP CODE:
E-MAIL:
HOME PHONE: (
)
-
CELL PHONE: (
)
-
EMERGENCY CONTACT:
NAME:
RELATIONSHIP:
PHONE NUMBER: (
)
AGE:
GENDER:
MALE
FEMALE
RACE:
AMERICAN INDIAN OR ALASKAN NATIVE
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
ASIAN
WHITE
BLACK OR AFRICAN-AMERICAN
MULTI-ETHNIC
HISPANIC OR LATINO
UNKNOWN
CITIZENSHIP AND PUBLIC SERVICE STATUS:
US CITIZEN
PERMANENT RESIDENT
OTHER (Country of Origin):
ARE YOU ELIGIBLE TO WORK IN THE U.S.?
YES
NO
ARE YOU A VETERAN?
YES
NO
NATIVE LANGUAGE (if other than English):
EMPLOYMENT STATUS AND HISTORY
EMPLOYMENT STATUS (Please check all that apply):
EMPLOYED (specify):
FULL-TIME
PART-TIME
EMPLOYED BUT MY PAY OR HOURS ARE NOT SUFFICIENT FOR MY FAMILY’S BASIC NEEDS
UNEMPLOYED AND LOOKING FOR WORK
UNEMPLOYED AND NOT LOOKING FOR WORK
ARE YOU A DISLOCATED WORKER?
YES
NO
A dislocated worker is an individual 20 years of age or older who either left or lost his or her job because the company
closed, relocated, abolished their position or shift, or did not have enough work to give the employee.
EMPLOYER NAME (current or most recent):
REASON FOR LEAVING (if applicable):
JOB TITLE:
JOB DUTIES:
START DATE:
/ /
END DATE:
/ /
HOURLY WAGE: $
HOURS PER WEEK:
FULL-TIME
PART-TIME
INCOME ELIGIBILITY
NUMBER OF INDIVIDUALS IN YOUR HOUSEHOLD:
DO YOU HAVE PRIMARY RESPONSIBILITY FOR SUPPORTING THE INDIVIDUALS IN YOUR HOUSEHOLD?
YES
NO
GROSS FAMILY INCOME FROM THE LAST 12 MONTHS: $
*Gross income is the total family income before taxes and deductions.
DO YOU RECEIVE ANY OF THE FOLLOWING:
FOOD ASSISTANCE (formerly known as FOOD STAMPS:
YES
NO
TANF/PROMISE JOBS:
YES
NO
SOCIAL SECURITY/DISABILITY
YES
NO
GENERAL ASSISTANCE:
YES
NO
ARE YOU CURRENTLY RECEIVING OTHER FINANCIAL ASSISTANCE?
YES
NO
IF YES, PLEASE LIST THE
PROGRAMS HERE:
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Parent category: Business