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Pre-Screening
Name
SSN
Address
City
State
Zip
Date
Phone
Email
Do you reside in Allen County?
Yes
No
Are you a United States Citizen or eligible to work in the United States?
Yes
No
Males born after 1960 - Have you registered with Selective Service?
Yes
No
Total number of people in household?
Total number of children living in the household?
Are you currently employed?
Yes
No
If yes, what is your hourly wage
Average hours per week?
If no, list your most recent employer
End date with that employer
If married, is your spouse employed?
Yes
No
Spouse wage per hour
Average hours per week
Are you laid off?
Yes
No
If yes, from what company?
Layoff date:
Wage at layoff
Recall expected?
Yes
No
Expected date of return if known:
Do you have an Associates, Bachelor’s, or Master’s Degree or a recognized certification?
Yes
No
If yes, list degree or certification and year attained
If you are interested in starting (or currently enrolled in) training, please list:
School/Training Provider
Education/Training Program
Cost of Training
Expected Dates of Training
If you are interested in a paid internship/work experience, please list
Employer
Internship Position
Date available to start internship
Submit
