Job Placement Questionnaire (WIOA) 2023
Please fill out the Job Placement Questionnaire so that we can address your barriers. Our goal is to assist you in finding suitable training, education, or a career that will lead to stable work and productivity for your household. 
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Email *
Date *
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Time
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First Name *
Last Name *
Date of Birth *
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Social Security Number
 Please note that this information will not be shared with anyone and will be kept confidential. This information is necessary so that Workforce Solutions can track your progress within our program.
Social Security Number *
Street Address *
City *
State *
Zip Code *
Phone *
Email *
Sex/Gender *
Required
Do you have a Disability? *
Ethnicity *
Required
Are you a Veteran? *
Are you (GI Bill) Eligible Veteran? *
Are you a Disabled Veteran? *
Are you a homeless veteran? *
Are you a displayed homemaker? *
Are you employed? *
Do you have a criminal background? ( Please note that we do not discriminate against those who have backgrounds because we offer second chance employment.)
 *
Do you receive TANF,  SNAP, or SSI Social Security Disability  ?
 *
Required
What is the highest completion of education?  *
If you haven't obtained an education, would you be willing to pursue one? *
What Apprenticeship Program Are You Interested In?
 *
Required
Do you have work experiences, if so  in what type of industry? *
Required
Is there a certain type of Industry you're wanting to gain a career in? If so, could you please explain? *
Required
What are your strengths? *
What are your weakness? *
Are there some barriers in your life that are preventing you from becoming successful? If so, can you please explain? *
Required
Where would you like to see yourself in a couple of years?
What are your current needs ( please check all that apply)
THANK YOU!
We appreciate your determination in filling out this questionnaire and want you to know that Urban Community Network will use the information on this form to assist us with finding solutions to address your barriers.
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