Screening

Name:

SSN:

address:

city:

state:

zip:

birthdate:

phone:

email:

Do you reside in Allen County? yes no

Are you a United States Citizen or eligible to work in the United States? yes no

Males born after 1960 – Have you registered with Selective Service? yes no

Total number of people in household?:

Number of minor children living in the household?:

Are you currently employed? yes no

If yes, what is your hourly wage?

Average hours per week?

If no, list your most recent employer

End date with that employer

If married, if your spouse employed? yes no

Spouse wage per hour?

Average hours per week?

Are you laid off? yes no

If yes, from what company?

Layoff date:

Wage at layoff

Recall expected? yes no

Expected date of return if known

Do you have an Associates, Bachelor’s, or Master’s Degree or a recognized certification? yes no

If yes, list degree or certification and year attained

If you are interested in starting (or currently enrolled in) training, please list:

School/Training Provider

Education/Training Program

Cost of Training

Expected Dates of Training

If you are interested in a paid internship/work experience, please list

Employer

Internship Position

Date available to start internship