Equipping and Empowering Job Seekers to Become Excellent Employees

“Equipping and empowering job seekers to become excellent employees”

Program Application

Referral Agency:

Referred By:

CFJI Location you are applying to:

Willow Creek Church (Seminole County) Nova Southeastern University (Orange County)

Contact Information

Name:

Last First Middle

Address:

Phone # Email

Recent Employment History

Please document your most recent work history beginning with your most recent job

1. Company:

Dates: to Title/Position:

Supervisor: Phone

Duties:

2. Company:

Dates: to Title/Position:

Supervisor: Phone

Duties:

3. Company:

Dates: to Title/Position:

Supervisor: Phone

Duties:

Education Level

Highest Level of Education Attained: Code:

1. HS Diploma or GED

2. AA/AS Degree

3. Some College No Degree

4. Bachelor’s Degree

5. Graduate Degree or Certificate

Additional Certifications/Skills/Training:

Background Information

Have you ever been convicted of a felony or first degree misdemeanor? Yes No

If yes, what charges?

Where? Date of conviction:

Have you ever pled Nolo Contendere or pled guilty to a crime which is a felony or first-degree misdemeanor? Yes No

If yes, what charges?

Where? Date:

Have you ever had the adjudication of guilt withheld for a crime which is a felony or a first-degree misdemeanor? Yes No

Where? Date:

Note: An affirmative answer will not automatically disqualify you from participation. The nature, severity, and date of the offense are considered.

Citizenship

Are you a U.S. Citizen? Yes No

If “no”, are you legally authorized to accept employment in the U.S.? Yes No

Americans with Disabilities Act

Are there any reasonable accommodations that you require in order to participate?

Yes No

If “yes”, please list:

Emergency Contact

In case of an emergency, please provide the name of someone who you would like us to contact:

Name: Relation to participant:

Phone: ( ) Address:

Certification

I am aware that any omissions, misstatements, falsifications, or misinterpretations may disqualify me from consideration in the Central Florida Jobs Initiative training program. I understand that any information I give may be investigated as allowed by the law. I attest that all information submitted is true, correct, and complete to the best of my knowledge. :

Signature: Date:

CFJI Participant Survey

The following information will be used only for participant tracking purposes. The answers to these questions will not be used to determine eligibility for the training program and will be removed before application review.

Gender: Male Female

Race/Ethnicity: Household Type:

1. White/Caucasian 1. Married/ Couple with Children

2. Black/African American 2. Married/ Couple without Children

3. Asian/Pacific 3. Single Female with Children

4. Hispanic/Latino 4. Single Female without Children

5. Native American 5. Single Male with Children

6. Mixed/Biracial 6. Single Male without Children

7. Unknown 7. Extended/ Multi-Family with Children

8. Other 8. Extended/ Multi-Family without Children

9. Other

10. Unknown

Employment: Household Income:

1. Employed 1. Less than $25,000

2. Unemployed 2. $25,001 - $50,000

3. Retired 3. $50,001 - $100,000

4. N/A (Not expected to work) 4. $100,000+

5. Unknown 5. Unknown

County of Residence: Age:

1. Orange County 0-4

2. Osceola County 5-93

3. Seminole County 10-14

4. Other 15-19

5. Unknown 20-34

35-54

55-64

65+

Unknown

Referral Agency/Office Use Only

Notes:

A Program of

1