Work Program Intake Form
Complete the following information to the best of your ability. Bring this completed form to your appointment. /For Office Use Only
Enrollment Date:Last Name First Name MI
/ Case Manager:PIN: / Case:
ES Worker:
Social Security Number: / Are you a Migrant Worker: No Yes
Refugee: No Yes, Entry Date:______
Vietnamese Hmong Laotian
Cambodian Cuban Other______/ Veteran: No Yes, type of discharge______
Dates:_____/_____/_____to_____/_____/____
Phone: / Message #: / Tribal Member: No Yes: ______
Education & Transportation Information
List last grade completed in school and the year it was completed: Grade______Year______/ Vehicle Available: Yes NoDriver’s License:Yes State___
If No, explain: / Liability Insurance:
Yes No
I have a: High School Diploma GED HSED
List any vocational/college training you have had:1.Course/Major______Dates:______
Location:______
2.Course/Major______Dates:______
Location:______/
Other Transportation Available: Yes No
If Yes, Explain:I’m willing/able to travel ______miles to a job.
I’m willing to relocate: Yes No
Explain:Employment Search Information:
The kind of job I want is: /I have used JOBNET in the past week: Yes No
I prefer to work the following hours on these days:(such as 8am-5pm or 11pm to 6am, etc.)
Mon:______Tues: ______Wed:______
Thur:______Fri:______Sat:____ Sun:_____
The last time I looked for a job was:
I have a current resume: Yes No
I have a list of references: Yes No
/ I cannot work the following hours/days:Because:
I have missed work in the past because:
Skills and Abilities:
List any certifications/licenses you have:(CDL, CNA, PCW, etc.)
1.______Date received:______
2.______Date received:______
3.______Date received:______/ List any other languages you know:
1.______Speak Write
2.______Speak Write
Do you type: No Yes – words per minute:_____
Familiar with computers: No YesList any equipment you can use: / Software applications I know:
Employment History: (list most recent employment first)
Employer: / Employer: / Employer:Location (city): / Location (city): / Location (city):
Position: / Position: / Position:
Pay: / Hours/wk: / Pay: / Hours/wk: / Pay: / Hours/wk:
Health Insurance: Yes No / Health Insurance: Yes No / Health Insurance: Yes No
Other Benefits: Sick Leave
Vacation Other benefits / Other Benefits: Sick Leave
Vacation Other benefits / Other Benefits: Sick Leave
Vacation Other benefits
Reason For leaving: / Reason for leaving: / Reason for leaving:
Dates:______to______/
Dates:______to______
/ Dates:______to______Employer: / Employer: / Employer:
Location (city): / Location (city): / Location (city):
Position: / Position: / Position:
Pay: / Hours/wk: / Pay: / Hours/wk: / Pay: / Hours/wk:
Health Insurance: Yes No / Health Insurance: Yes No / Health Insurance: Yes No
Other Benefits: Sick Leave
Vacation Other benefits / Other Benefits: Sick Leave
Vacation Other benefits / Other Benefits: Sick Leave
Vacation Other benefits
Reason For leaving: / Reason for leaving: / Reason for leaving:
Dates:______to______/
Dates:______to______
/ Dates:______to______Barriers:Please identify any barriers you or a family member has that is interfering with you getting/keeping a job:
I have been convicted of a crime(s): Yes NoIf Yes, identify conviction(s) and date(s)
Conviction:______Date:______
Conviction:______Date:______/ I am currently on Probation/Parole: Yes No
If yes, Name of PO Officer:______
Phone Number of PO Officer:______
When is your Probation/Parole up?______
I have an alcohol problem: Yes No
If yes, are you receiving treatment: Yes No
If yes: Where:______When:______/ I am using drugs: Yes No
I am or have been in a drug treatment program: Yes No
If yes: Where:______When:______
Other Barriers / Person with Barrier / When did it start? / Has it been verified by a Doctor, counselor, etc.?
No
Yes, by:
No
Yes, by:
No
Yes, by:
Other Agency Involvement: Please identify any agencies you or family member(s) are working with:
Name of Agency
/ Who is involved with the agency / Why?Family Information
1. Rate your living situation on a scale from 1 - 10 (10 being best)______. Why?
2. I feel best about myself when:
3. Are you currently or have you recently experienced any problems in your personal relationships:
No Yes, explain:
How could they be resolved:
4. The following friends/family members have helped me in the past year:
5. What was the last problem you solved on your own and how did you solve it:
6. What do you do well (list your strengths and successes)
7. Why do you think you are unemployed or not fully employed at this time:
8. I would like the following things different in my life right now:
9. In two years I would like to be:
10. List any questions you have: