CLIENT REGISTRATION FORM
Event
:
None
Goodwill Registrations - 1/28/21 - Lewis Center
Palm Beach State Weekly Visit - 1/18/38 - Palm Beach State, Lake Worth
Demographic Profile
First Name
*
:
Last Name
*
:
M.I. :
Current Address
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:
City
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:
State
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:
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
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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?
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Yes
No
First Military Service
Start Date
:
End Date
:
Branch of Service:
Please Select...
Army
Navy
Air Force
Marine
Coast Guard
Most Recent type of Discharge:
Please Select...
Honorable
General
Other than Honorable
Bad Conduct
Dishonorable
Uncharacterized
Did you serve more than 1 tour of duty?
Yes
No
Did you serve in the Republic of Vietnam anytime during 2/28/1961 – 5/7/1975?
Yes
No
Have you received a Military Campaign Badge?
Yes
No
Homeless Veteran?
Yes
No
Disabled Veteran?
Yes, 30% or more
Yes
No
Received Services from Veterans Voc. Rehab. (Chapter 31)
Yes
No
Unknown
Are you currently incarcerated or have you been released from incarceration?
Yes
No
Unknown
Within the last 12 months, have you been unemployed for 27 or more weeks?
Yes
No
Unknown
I agree to have my job seeker account created/updated on EmployFlorida.com and agree to be referred to qualifying job openings for at least a year, or until reaching employment.
*
By typing your name below, you agree that will be used as your signature.
Signature(Enter your full name)
*
:
Date
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