JFLapp

Address *

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City

State

Zip Code

Country

Date of Birth: *

Gender *

Male Female

Ethnicity: *

WORK STATUS

Are you a United States Citizen? *

Yes No

If no, can you provide proof of residency? *

Yes No

Are you currently legally authorized to work? *

Yes No

If no, are you in the process of securing work authorization? *

Yes No

1. US Social Security Card *

Yes No

US Green Card *

Yes No

Driver's License *

Yes No

Please list any physical handicaps (if you have none put N/A) *

EDUCATIONAL BACKGROUND INFORMATION

Highest Grade Completed *

Did you receive a certificate or diploma from a college or training facility? *

Yes No

Security

Do you have a criminal history? *

Yes No

Have you ever been convicted of a felony and/or served time in the past? *

Yes No

If Yes, please describe below. Note: Providing this information will not disqualify a person from becoming a Jobs for Life student.

Incident *

Year *

City/State *

Charge & Release Date *

Incident *

Year *

City/State *

Charge/ Release Date *

Are you willing to take a drug test? (See Instuctions) *

Yes No

Current Employment Status

Check all that apply

Choose Any *

Unemoloyed Part-time job Self-employed Retired

Jobs For Life Training Information

Do you have reliable transportation *

Yes No

What is your reason for taking Jobs for Life training? *

Previous Work Experience

List your last four employers, starting with your most recent or current emplyer. Include military and volunteer experience. Be as complete as possible.

Business Name: *

Phone Number *

Start Date: *

End Date: *

Address *

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City

State

Zip Code

Country

What is/was your job title? *

What are/were your duties? *

Who is/was your supervisor? *

If you are no longer employed here, why did you leave? *

Business Name: *

Phone Number *

Start Date: *

End Date: *

What is/was your job title? *

What are/were your duties? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Who is/was your supervisor? *

If you are no longer employed here, why did you leave? *

Business Name: *

Phone Number *

Start Date: *

End Date: *

What is/was your job title? *

What are/were your duties? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Who is/was your supervisor? *

If you are no longer employed here, why did you leave? *

Business Name: *

Phone Number *

Start Date: *

End Date: *

What is/was your job title? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Who is/was your supervisor? *

What are/were your duties? *

If you are no longer employed here, why did you leave? *

This Section for referring church/organization/individual use only (if no referral, leave blank):

Phone Number *

Email *

Pastor/Director's Name *

Pastor/Director's Email *

Address *

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City

State

Zip Code

Country

Jobs for Life Applicant Background Information

Please note that your responses to any and all of the following questions WILL NOT disqualify you from participating in Job for Life. JfL leaders will keep all personal information disclosed on this form confidential.

General Information

WORK STATUS

EDUCATIONAL BACKGROUND INFORMATION

Security

Current Employment Status

Check all that apply

Jobs For Life Training Information

Previous Work Experience

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