RAPID RESPONSE CLIENT REGISTRATION FORM
Event
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Demographic Profile
First Name
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Last Name
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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 #
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Email
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Date Of Birth
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SSN
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Current Employer
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Current Job Title
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Receiving unemployment insurance?
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Please select
No, neither claimant or exhaustee
No
Yes, Exhaustee
Yes, Claimant referred by PREP
Yes, Claimant, not referred by PREP
Highest level of education?
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Please select
Less than High School
High School Diploma
GED
Some College
Associates
Bachelors
Masters
Doctorate
Last Grade Completed?
Which of the below services would you be most interested in receiving?
Resume Assistance
File for Unemployment
Labor Market Information
Job Search Assistance
One-on-one career consulting
Invitation to upcoming hiring events and Job Fairs
Which of the following programs are you most interested in receiving?
Veteran Services & Grants
Disability Services
Youth & Young Adult
Snap & Temporary Assistance
Background Challenged Services
On-The-Job Training
Which workshops/seminars would you be most interested in attending?
Resume Workshop
Interviewing Skills Workshop
LinkedIn Workshop
Professional Placement Network
Please select your race from the list
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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
Are you of Hispanic or Latino Heritage?
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Yes
No
Gender
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Male
Female
Do Not Wish to Disclose
Registered for Selective Service?
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Yes
No
N/A
Are you a US citizen?
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Yes
No
Are you a Permanent Resident/Green Card holder?
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Yes
No
Alien Registration #:
Expiration Date:
Do you have a disability?
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Yes
No
Do Not Wish to Disclose
Have you worked as a Migrant Seasonal Farm Worker within the last 12 months?
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Yes
No
Military Service
Are you currently in the military, a veteran, or spouse of a veteran?
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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
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Date
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