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Job Seeker Input Form
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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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Email address
*
Your answer
Phone
*
Your answer
Job/Career Interest Areas
*
Your answer
Please tell us a little more about your situation
Your answer
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
Required
Have you been a part of our program and been assigned a mentor in the past?
*
Yes
No
If "Yes," who was your mentor?
Your answer
Thank you!
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