CLIENT REGISTRATION FORM
Event
:
None
PBSC - 01/01/2019 - LAKEWORTH
Demographic Profile
First Name
*
:
Last Name
*
:
M.I. :
Current Address
*
:
City
*
:
State
*
:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
*
:
Phone #
*
:
Email
*
:
Date Of Birth
*
:
SSN
*
:
Please select your race
:
Please select
White or Caucasian
Black or African American
Asian
American Indian or Alaska Native
Hispanic or Latino
Native Hawaiian or Pacific Islander
Other
Do not wish to answer
Highest level of education?
*
Please select
High School Diploma
GED
Less than High School
Some College
Associates
Bachelors
Masters
Doctorate
Desired Job
*
:
Receiving unemployment insurance?
*
Please select
No, neither claimant or exhaustee
No
Yes, Exhaustee
Yes, Claimant referred by PREP
Yes, Claimant, not referred by PREP
Gender
*
Male
Female
Registered for Selective Service?
*
Yes
No
Are you a US citizen?
*
Yes
No
Are you a Permanent Resident/Green Card holder?
*
Yes
No
Alien Registration #:
Expiration Date:
Do you have a disability?
*
Yes
No
Have you worked as a Migrant Seasonal Farm Worker within the last 12 months?
*
Yes
No
Military Service
Are you currently in the military, a veteran, or spouse of a veteran?
*
Yes
No
Are you the spouse/dependent of someone in
Active Duty
of the Military, National Guard, or Reserves?
Yes
No
Are you a current member of the Florida National Guard?
Yes
No
Are you within 24 months of retirement or 12 months of discharge from the military (Transitioning Service Member)?
Yes
No
Have you served on active duty in the Armed Forces and were discharged or released from such service under conditions other than dishonorable?
Yes
No
Are you the spouse of a veteran who has a total service connected disability, is missing in action, captured in the line of duty by hostile forces, a prisoner of war, or who died from a service connected disability?
Yes
No
Are you now or have you served in a National Guard or Reserve unit that was called to or is on active duty due to armed conflict and/or crisis involving National Security (Title 10 Activation)?
Yes
No
I agree to have my job seeker account created and/or updated at EmployFlorida.com
*
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