Goodwill Job Connection Center- Intake Form
This form is for those who this is their FIRST time in the Job Connection Center or those who it has been their first time since 01/01 of the calendar year since their last visit.
Is this your first time in the Job Connection Center? *
First Name *
Last name *
Physical Address *
City *
State *
Zip Code *
Phone Number (Area Code First) *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Last 5 Digits of Your Social Security Number *
What gender do you most closely identify with? *
Are you any of the following? *
Required
What ethnicity do you represent? *
Is your primary language Spanish? *
Are you a United States citizen? *
What is the highest level of education that you have attended? *
Who referred you to Goodwill? *
What is your annual household income? *
What is your household size? (how many people are you financially responsible for?) *
How many children? *
Are you receiving SNAP (Food Stamps)? *
Are you receiving TANF? *
Do you have a disability of any of the following? Check all that apply. *
Required
Please select if any of of the following apply to you: *
Required
At Goodwill, we work with many people who are unemployed or underemployed. What is your employment situation like? Tell us how long you have had this employment situation. *
E-Signature *
Submit
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