Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Is the above a cell phone number? *

YES

NO

Do you have a High School diploma or H.S. Equivalent Degree (GED)? *

YES

NO

Do you have a resume?

YES

NO

When was the last time you were employed? *

MM

DD

YYYY

When was your last job interview? *

MM

DD

YYYY

If employed, will you need transportation assistance to go to and from work? *

YES

NO

What is preventing you from working? (check all that apply) *

LACK OF CHILDCARE

YOU ARE DISABLED

CARETAKER OF ELDERLY OR DISABLED PERSON

LACK OF WARDROBE

LACK OF TRANSPORTATION

DIFFICULTY WORKING WITH OTHERS

NEED MORE EDUCATION/CREDENTIALS

ANGER, NEED SOMEONE TO TALK TO?

LACK OF SUPPORT FROM FAMILY/FRIENDS

Are you personally receiving TANF/Food Stamps? *

YES

NO

Are you currently pregnant or have children? *

YES

NO

Have you or anyone in your household been diagnosed with COVID-19 (Coronavirus) *

YES

NO

Are you currently registered with ILWorkNet? *

YES

NO