TEXAS WORKFORCE NETWORK

WORK REGISTRATION

(This is not a registration for Unemployment Insurance benefits.)

Welcome to TWC / Please fill in this application completely / Please Print
1. Last Name / First Name / Middle Initial / 2. Social Security Number
- / -
3. Mailing Address / E-mail Address
City / State / Zip Code / County / 6. Telephone Numbers
Home / Leave Message
TXAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMN / or
Disclosure of the following information is voluntary and the information obtained will only be used for statistical purposes.
7. Are you a military veteran? (Check One) Yes No / ATTENTION VETERANS This information is voluntary.
Active duty dates: / Mo: / Day: / Yr: / TO / Mo: / Day: / Yr: / Disclosure of this information is NOT required for provision of
Branch / Services by TWC. Do you have a service connected disability?
(check one) Yes No If yes, what percent? %
Sex: / Male / Female / Birth Date
Race/Ethnic: / 1 White-Non Hispanic / 2 Black - Non Hispanic / 3 Hispanic
4 American Indian/American Native / 5 Asian - Non Hispanic / 6 Is Not Ascertainable
7 Hawaii Native & Pacific Islander - Non Hispanic
8. Education (select highest grade completed) / (30 semester hours = 1 year of college. / Degree Received
GED Yes No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 / Major
9. Work History: Describe your most recent job, include your past 18 months of work experience, including military.
A. Company Name / Job Title / How many months were you employed / Salary / $
Per (Check one)
c/o / Date Started / Date Ended / Hour (1) Day (2) Week (3)
Mo Day Yr / Mo Day Yr / Month (4) Year (5) Other (60)
Street or P O Box / Reason for leaving (check one)
Telephone Number / Layoff-Permanent(1) Quit (2)
City / State / Zip Code / () / - / Fired(3) Layoff-Temporary (5)
TX / Recall Date:
Describe job duties: Include tools and equipment used, process involved, products made, services rendered, type of business. / Mo / Day / Year
Work History Continued: Describe two other jobs related to the type of work you are looking for (not including the one above)
B. Company Name / Job Title / How many months were you / Salary $ / $
employed? / Per (check one)
M M Y Y / Hour (1) Day (2) Week (3)
Describe job duties: Include tools and equipment used, process involved / Date Ended / Month (4) Year (5) Other (06)
Reason for leaving (check one)
Layoff (1) Quit (2)
Fired (3) Still Employed (0)
C. Company Name / Job Title / How many months were you / Salary $ / $
employed? / Per (check one)
M M Y Y / Hour (1) Day (2) Week (3)
Describe job duties: Include tools and equipment used, process involved,etc. / Date Ended / Month (4) Year (5) Other (60)
Reason for leaving (check one)
Layoff (1) Quit (2)
Fired (3) Still Employed (0)
What kind of work will you accept? / 10. / 1st choice / 2nd choice
Lowest salary you will accept on a job: / 11. / $ / Per (check) / Hour1 / Day2 / Week3 / Month4 / Year5
Check work week you will accept: / 12. / Full-time1 / Part-time2 / Either
Check shifts you can work: / 13. / Any / Days1 / Evenings2 / Nights3 / Rotating4 / Split5
Do you attend any type of school? / 14. / Full-time / Part-time / No / Your schedule
Special courses taken (Military, Vocational, Technical): / 15.
Do you need bus transportation to get to work? / 16. / Yes3 / No
How many miles will you drive one way: / 17.
In what area of town will you work? / 18.
Will you relocate for a job? / 19. / Yes / No
In what other Texas cities will you work? / 20.
Check your driver's license type? / 21. / Class C1 / Class B2 / Class A3 / ICC4 / CDL / Endorsements?
Do you have a license (Electrician, LVN)? / 22. / Yes1 / No / If yes what kind?
Do you have a certification (Nurse Aide, Medication Aide, etc)? / 22a. / Yes1 / No / If yes what kind?
Can you take dictation? / 23. / Yes / No / If yes, WPM
Can you type? / 24. / Yes / No / If yes, WPM
Can you use a keyboard? / 25. / Yes / No
Can you operate a personal computer? / 26. / Yes / No
If yes, list type and software: / 27.
Do you have your own tools (mechanic, carpenter)? / 28. / Yes / No / If yes, what kind?
Languages (other than English) do you speak, read, or write? / 29.
30. Additional Information:
Individuals may receive, review, and correct information that TWC collects about the individual by emailing to or writing to TWC Public Information, Rm 264, 101 East 15th, Austin, TX 78778-0001.
31. I have received notification concerning Equal Opportunity is the Law. 1
Signature / Date
32. KEYWORDS: / PLEASE SELECT KEYWORDS THAT REFLECT YOUR MOST RECENT JOB AND THE KIND OF WORK YOU ARE LOOKING FOR.
Number / Mo Ex / Keyword/Term / Number / Mo Ex / Keyword/Term
33. Summary:
WORKFORCE CENTER USE ONLY
34. DOT Code (1) / 35. Mo Exp / 36. JBID / LOC 1 / LOC 2 / LOC 3 / 37. Work
ZN / RNG / NOT / ZN / RNG / NOT / ZN / RNG / NOT / Tolerance
1-6
DOT Code (2) / Mo Exp / 40. Food Stamp & ENT / 41. Emp Stat / 42. RIO / 43. WIA / 44. Dislocated / 45. Ext
0-5 / 1Employed / 1, 2, 4, 5 / Elig / Worker / Stat

EXEMPTION

/ 2Unemployed / Yes / 1-9 Yes / 1-9 Yes / 1-4
38. Veteran / STATUS / 1Medical / 5Child / 46. Econ Dis / 47. Welfare To Work / 48. MSFW
1 Vietnam / 2Other / 3Oth Elig / 1Mand / 2Lang / 6Migrant / 1Yes / 1Wk. Reg Reqd. / 1Farm Wkr / 2MFW
4 Other w/Campaign / 2Vol 3Cured / 3Tran / 7Other / 2Homeless & / 3Welfare-Other / 3Migrant Food Processing
39. Recent Separation / Date / 4Reconsid / 4Remove / 9Special / Disadvantaged
1 12 Months or less / 2 13-48 Months / Reserved / 50. Educ Stat / Summer 51. Youth / 52. Elig Claimant
Client# / 1In School / 1Year Round / 1State / 2Other
2Not in Sch / 2Summer / 3Ext Ben / 4Fed Use
54. COUNTY CODE / 55.WDA / 56. LOFF / 57. STA/DESK / 58.REG DATE

ES-511 (0202)