CSPBCAPPS

CLIENT REGISTRATION FORM

Demographic Profile

How did you hear about us?*

First Name *:

Last Name *:

M.I. :

Current Address *:

City *:

State *:

Zip *:

Phone # *:

Email *:

Date Of Birth *:

SSN *:

Receiving unemployment insurance?*

Desired Job*:

Highest level of education?*

Last Grade Completed?

Please select your race from the list:

Are you a Palm Beach State College Student or Alumni? *

Yes No

Are you of Hispanic or Latino Heritage? *

Yes No

Gender *

Male Female Do Not Wish to Disclose

Registered for Selective Service? *

Yes No N/A

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 Do Not Wish to Disclose

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

This information will be used to create or update an account on EmployFlorida.com and for referrals to be made to qualified job openings. I acknowledge recruiters may contact me regarding job opportunities and agree with Terms of Use of www.EmployFlorida.com*

By typing your name below, you agree that will be used as your signature.

Signature(Enter your full name) *:

Date *:

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