Job Seeker Input Form

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Please complete this short form. We use this information to get in touch with you and to assign a mentor to you, if requested.

All information is confidential.

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Last Name *

First Name *

Email address *

Phone *

Job/Career Interest Areas *

Please tell us a little more about your situation

How long have you been looking for a job? *

<6 mos

6-12 mos

1-2 years

>2 years

Prefer not to answer

Highest Level of Education *

High school

Trade, community college, or other associate degree (2 year)

Undergraduate college (4 year)

Graduate education (Masters or PhD)

Prefer not to answer

Gender *

Female

Male

Other

Prefer not to answer

Age *

Under 26

26-39

40-49

50-59

Over 60

Prefer not to answer

How did you find out about us? *

I am a past participant

Referred by a current or past participant

Referred by a family member, friend, mentor, or colleague

Referred by a recruiter or staffing agency

Referred by WorkSource, career coach, job support, or other networking group

Learned about Job Seekers from my church, school, or professional organization

Website search, social media, or other online source

Obligatoire

Have you been a part of our program and been assigned a mentor in the past? *

Yes

If "Yes," who was your mentor?

Thank you!

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