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Goodwill Job Connection Center- Intake Form
This form is for those who this is their FIRST time in the Job Connection Center or those who it has been their first time since 01/01 of the calendar year since their last visit.
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* Indicates required question
Is this your first time in the Job Connection Center?
*
No
Yes
First name
*
Your answer
Last name
*
Your answer
Street address
*
Your answer
City
*
Your answer
Oklahoma
*
Choose
Oklahoma
Texas
Other
Zip Code
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Birth date
*
MM
/
DD
/
YYYY
Social Security number
*
Your answer
What gender do you most closely identify with?
*
Female
Male
Prefer not to say
Transgender
Non-Binary
Other:
Military Status
*
Active Duty or Prior Military
Military Spouse or Military Family
Caregiver of a Person in the Military
History of Military Service
No History of Military Service or Military Family
Required
Race/Ethnicity
*
African American, Black
American Indian, Eskimo or Inuit (Native American), First Nation
Asian, Native Hawaiian, Pacific Islander
Caucasian, White
Latino, Hispanic
Other (Including Multi-Racial)
Is your primary language Spanish?
*
Yes
No
Are you a United States citizen?
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Yes
No
What is the highest level of education that you have attended?
*
No history of education completed
8th Grade or Below
9th Grade
10th Grade
11th Grade
High School Diploma/GED
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Post Doctoral Studies
Who referred you to Goodwill?
*
Self or Walk-In
Referral From Goodwill Employee or Service
I am a Goodwill Employee
American Association of Retired Persons (AARP) or the SCSEP Program
Veterans Affairs or Veteran Services Organization
Corrections or Justice System (Adult)
TANF Office
Other Agency Not Listed
What is your annual household income?
*
0-$18,650
$18,651-$37,950
$37,951-$51,800
$51,801-$77,400
$77,401-$153,100
Over $153,101
What is your household size? (how many people are you financially responsible for?)
*
Your answer
How many children?
*
Your answer
Are you receiving SNAP (Food Stamps)?
*
Yes
No
Are you receiving TANF?
*
Yes
No
Do you have a disability of any of the following? Check all that apply.
*
Autism Spectrum Disorder (including Aspergers)
Visual Impairment or Blindness
Deafness or Hard of Hearing
Developmental Disability (Not Autism)
Emotional Disability
Learning Disability
Neurological Disability
Physical Disability
NONE, I do not have a disability.
Required
Please select if any of of the following apply to you:
*
History of substance abuse
Homeless
Immigrant
Insufficient childcare
Transportation issues
Lesbian, Gay, Transgender, Queer (LGBTQ+)
History of criminal background
Refugee
Dislocated worker
Unemployed
Underemployed
None of these apply to me
Required
At Goodwill, we work with many people who are unemployed or underemployed. What is your employment situation like? Tell us how long you have had this employment situation.
*
Your answer
Signature
*
Your answer
Submit
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