Laserfiche WebLink
<br />Initial Visit: <br /> <br />~ <br />~Nb~Ji <br />W,o;RiH <br />_. <br />,;<, . <br /> <br />Santa Ana W/O/R/K Center <br />Client Information (Please print clearly) <br />Badge #: Referred By: FEZ: <br /> <br />spa Date: <br /> <br />Yes 0 No 0 <br /> <br />Last Name <br /> <br />Date: <br />Permanent Residence? <br />Zip Code: Is this residence a Shelter? <br />Alternate Telephone: ( ) <br /> <br />{Yes {No <br />{Yes {No <br /> <br />First Name: <br />Street Address: <br /> <br />City: <br />Home Telephone: ( <br /> <br />U.S. Citizen? { Yes {No If No, "Au #: or Work Permit #: <br />Sex: { Male { Femaie Date of Birth: _ / _ / 19 _ Social Security #: <br /> <br />CA Driver License {Yes <br />o Multiple axle trucks (A) <br />U.S. Military Veteran? <br />D Special Disabled Vet. <br /> <br />{ No If Yes,please check type of license <br />o Bus 15 passengers or more (B) D Passenger car (C) D Motorcycle (M) <br />DYes DNo If Yes, please check type of Veteran <br />D Vietnam Era Vet. D Disabled Vet. D other Campaign Vet.D Other Vet. <br /> <br />Ethnicity: Please check all that apply <br />D Asian Indian D Cambodian D Chinese D Filipino D Guamanian DHawaiian <br />D Japanese D Korean D Laotian D Samoan D Vietnamese D Other Pac Isiand <br />o Other Asian D Black - African American D Hispanic or Latino <br />D American Indian/Alaskan Native D White D Other: <br />Education: Please check highest level completed <br /> <br />D 8th grade or less D 9th grade through 12th grade D High School/GED D Some post high school <br />D Associate degree D Other postsecondary school/training D Bachelors degree D Masters degree D Doctorate degree <br />In the last 12 months, have you worked as a farmworker or migrant cannery worker? DYes DNO <br />Are you receiving: Section 8 Housing Assistance? { Yes { No <br /> <br />Last Place of Employment <br /> <br />Job Title: <br /> <br />Wages: <br /> <br />Last Day Worked: <br /> <br />Job Duties: <br /> <br />Seeking Employment Information <br /> <br />Industry Experience: D Construction D Manufacturing D Retail Trade 0 Finance D Aerospace <br />D Food Processing 0 Electronics 0 Transportation 0 Technology 0 Service D other <br />Are you willing to relocate? {Yes {No Desired wages: <br />Job Titles Desired: <br />Occupational Experience: D Manager/Administrator 0 Sales (Cashier) D Services D Agricultural <br />o Professional/Technical 0 Clerical/Administrative 0 Production/Construction/Maintenance <br /> <br />Rev: 9/01 <br /> <br />HIWIAIClient Information! (Application)-Eng. <br />