Job Skills Training Program
Intake Application Form
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First and Last Name *
Today's date *
JJ
/
MM
/
YYYY
Program
X
Certified Nurse Assistant
Culinary Arts
CDL Class B
Welding
Construction
Carpentry
Plumbing
Customer Service
Other
Phone *
Street address *
City *
Zip Code *
Have you lived in the state of Virginia for the past year? *
Email
Date of Birth *
JJ
/
MM
/
YYYY
Gender *
Marital Status
X
Single/Head of Household
Married
Separated
Divorced
Widowed
How many children do you have? If none, type N/A. *
How old are your children?
Do you currently reside/live with:
X
Alone
With spouse/significant other
With children
With parents
With roommate
Shelter
Transitional home
Relatives
Other
Do you currently live in public housing? If so, which development? *
In case of an emergency, who should we contact (name and relationship)? *
What is the telephone number for your emergency contact person. *
Income
X
Wages (If employed)
TANF
SNAP
Unemployment
Child Support
Disability
Are you currently a VIEW participant with your local department of human services? *
Are you currently a SNAP-ET participant with your local department of human services? *
Substance Abuse Inventory *
Yes
No
Have you ever been addicted to drugs?
Have you ever been addicted to alcohol?
Have you completed a rehabilitative program?
Do you currently attend local support groups for addiction?
MEDICAL HISTORY *
Yes
No
Are you currently on medication?
Do you have any physical restrictions/limitations?
Are you physically capable of lifting at least 50-75 pounds?
Do you have any food allergies?
Are you currently pregnant?
Are you currently receiving counseling?
List all prescribed medications you are taking (enter 'none' if you are not currently taking medication). *
EDUCATIONAL HISTORY *
Yes
No
Are you a high school graduate?
Have you acquired a GED?
Have you completed technical/vocational school?
Have you acquired a professional license, certification or apprenticeship?
Do you have a post high school degree (i.e., Associates, Bachelor, Master)?
SKILLS
X
Data entry
Word processing
Microsoft Word
Microsoft Excel
Microsoft PowerPoint
Handled multiple phone line
Typing
Do you have any barriers that have prevented or prevents you from seeking/keeping a job? If yes, please check below all barriers that apply. *
Barriers
X
Homelessness (no set or permanent place to live).
Unable to maintain employment for more than 3 months.
No childcare due to lack of funds and/or inability to secure reliable provider.
Lack access to public transportantion due to: the hours of operation, pysical restrictions and/or cost.
Domestic violence (have been physically, sexually and/or emotionally abused).
No interest/motivation.
Criminal involvement suc as felony, assault, misdemeanor and/or probation.
Family problems.
Repeated absences, tardiness, inappropriate behavior.
Lack appropriate clothing attire.
Low self esteem.
Lack high school diploma/GED.
Lack technical/occupational skills.
Substance addiction (abuse of drugs and/or alcohol).
EMPLOYMENT HISTORY *
Yes
No
Have you ever been employed?
Are you currently employed?
1. Current Employer (name of company)
Dates Employed (start date and end date)
Job Title
Job Duties
2. Previous Employer (name of company)
Dates Employed (start date and end dates)
Job Title
Job Duties
3. Previous Employer (name of company)
Dates Employed (start date and end dates)
Job Title
Job Duties
CRIMINAL HISTORY *
Yes
No
Have you ever been convicted of an offense (including driving)?
Have you ever plead guilty of an offense?
Do you have a Nolle Prose for a convicted offense?
Are you currently on parole?
List the city and state in which the offense(s) occurred.
Please check your current needs
X
Childcare
Bus Passes/Tokes
Uniforms
Other
None
Have you participated in the TCCs Job Skills Training Program before? *
CANDIDATE AUTHORIZATION OF RELEASE
The information I have provided on the Job Skills Training Program (JSTP) Intake Application Form is true and accurate to the best of my knowledge. *
My e-signature below (type your first and last name) authorizes the release of this information to JSTP staff and funding agencies to determine eligibility for the program I am applying. *
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