Pacific Gateway Job Placement

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Ths form is to provide Pacific Gateway, the City of Long Beach's Workforce division with your information for job training and placement. Once you sign up, they will contact you to complete a virtual job training program of 20 years and we will work with them to place you in jobs.

What services/programs are you interested in?

Job Placement

Option 2

Other:

Your Name

Home Address

Primary Phone #

Alternate Phone #

Email Address

Date of Birth

YYYY

Age

Employment Status

Never Worked

Unemployed/Not Working

Employed Part-time (31 hours or less)

Employed Full-time (32 hours or more)

Clear selection

Education

Highest School Grade Completed 0-12

High School Diploma, GED, HiSET or IEP Attendance/Completion Attained

None

Yes - High School Diploma

Yes - GED

Yes - HiSET

Yes - Certification of Attendance/Completion of IEP

Current School Status

In School, High School or less

In School, Alternative School

In School, Post-Secondary

Not Attending School, Secondary School Dropout

Not Attending School, Secondary School Graduate (includes GED & HiSET)

Not Attending School, within age (14-17) of compulsory school attendance

Attending Any School

Yes

Clear selection

If Yes, School Name

Highest Education Level Completed Beyond High School (Check all that apply)

None

Some College

Attained a post-secondary technical or vocational certificate

Attained other post-secondary degree or certification

Attained an Associate’s (AA / AS) Degree

Attained a Bachelor’s (BA / BS) Degree

Attained a Degree beyond a Bachelor’s Degree

PUBLIC ASSISTANCE (Please check off all that apply. These circumstances will not prevent you from receiving services.)

You and/or an immediate family member are currently receiving CalWORKS (Cash Aid)

Your parents received CalWORKS (Cash Aid) in the past

You and/or an immediate family member are currently receiving General Relief (Cash Aid)

You and/or your immediate family are currently receiving SSI (Supplemental Security Income)

You and/or an immediate family member are currently receiving SNAP, EBT or CalFresh

You and/or an immediate family member are currently receiving WIC or Medi-Cal

You and/or an immediate family member are currently receiving low-income housing assistance (i.e. Section 8)

Your parent or immediate family member has received low-income housing assistance (i.e. Section 8) in the past

PERSONAL CIRCUMSTANCE(S) (Please check off all that apply. These circumstances will not prevent you from receiving services.)

You are a current or former foster youth

You are a current or former offender (probation or parole)

You have been arrested and/or convicted of a crime

You are homeless or at-risk of becoming homeless

You are a parent and/or expecting a child

You have a disability (learning, mental, physical)

You identify as LGBTQ+

You are age 14-18, short on high school credits & not expected to graduate on time

You are a current runaway or at risk of becoming a runaway

You are a current or former emancipated minor

You are currently in or have participated in a substance abuse recovery program

You are a current or former gang member or at-risk of becoming a gang member

You are a refugee

You are a naturalized citizen

You have a Legal Resident Alien Status

Your parent or immediate family member has been homeless (past or present)

Your parent or immediate family member has been involved in the justice system (currently or formerly incarcerated)

Your parent immigrated to the US (United States)

Other:

Family Size & Children

# of Family Members (Household)

How many children do you have in the following age groups:

Age 13 or younger

Ages 14 - 17

Do you need child care assistance?

Yes

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