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<br />Help us W/O/R/K with you <br /> <br />~..,.,.. <br />... r' <br /> <br />1 ..il . <br />W!l1iR/K <br />~. <br /> <br />PLEASE TAKE A MOMENT TO FILL OUT THIS FORM TO BETTER ASSIST US <br />IN MEETING YOUR NEEDS. THANK YOU. <br /> <br />Name: <br /> <br />55#: <br /> <br />Date: <br /> <br />Badge #: <br /> <br />PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY IINTEREST YOU: (PRESS FIRMLY) <br />Yes <br /> <br />Do you need to file for: Unemployment? <br />Disability? <br /> <br />Are you actively seeking employment? <br /> <br />Are you a U.S. Veteran? <br /> <br />Do you need to register with CaIJOBS? <br /> <br />Do you need help with a Resume, Job Search <br />Skills, or Interviewing Skills? <br /> <br />Are you interested in exploring how your <br />skills match the current jobs available in this <br />area? <br /> <br />What is your primary language? <br />o English 0 Spanish 0 Other <br />Vietnamese 0 <br /> <br />Would you like assistance with reading, math <br />or computer knowledge? <br /> <br />Would you like to obtain your GED? <br /> <br />Are you feeling down, discouraged or <br />stressed? <br /> <br />Problems with family or relationship? <br /> <br />Do you have a physical, emotional, or mental <br />disability that is an impediment to <br />employment? <br /> <br />Do you have a disability that needs a <br />worksite accommodation? <br /> <br />o <br />o <br /> <br />Are you unemployed due to Lay Off or Plant <br />Closure? <br /> <br />Did your company move outside U.S.? <br /> <br />Was your company affected by imports? <br /> <br />Yes <br /> <br />o <br /> <br />o <br />o <br /> <br />o <br /> <br />o <br />o <br /> <br />o <br /> <br />o <br /> <br />o <br /> <br />o <br />o <br /> <br />o <br /> <br />o <br /> <br />o <br /> <br />FOR YOUR CONVENIENCE REFERRAL INFORMATION FOR THESE SERVICES CAN BE FOUND ON THE <br />NEXT PAGE <br /> <br />Please Return White Copy to Reception <br />**Retain Yellow copy for self-directed referral to appropriate services** <br />H/WWap2800 Revised 6/16/05 <br /> <br />o <br />o <br />o <br /> <br />o <br /> <br />Are you 21 years of age or younger? <br /> <br />Do you receive CalWORKs / Food Stamps? <br /> <br />o <br /> <br />Do you need information on General Relief / <br />MediCal? <br /> <br />Vocational Rehabilitation Services? <br /> <br />Do you need shelter, help paying your utilities <br />or food supplies? <br /> <br />o <br /> <br />o <br />o <br /> <br />o <br /> <br />Do you have Legal Problems that affect your <br />ability to obtain / retain employment? <br /> <br />Credit Problems? <br /> <br />Do you require bonding for employment? <br /> <br />o <br /> <br />GLAD / Deaf Services? <br /> <br />o <br /> <br />Do you need Housing Assistance? <br /> <br />Are you over age 55 and of Low Income? <br />