Pacific Gateway Job Placement
Ths form is to provide Pacific Gateway, the City of Long Beach's Workforce division with your information for job training and placement. Once you sign up, they will contact you to complete a virtual job training program of 20 years and we will work with them to place you in jobs.
What services/programs are you interested in?
Your Name
Home Address
Primary Phone #
Alternate Phone #
Email Address
Date of Birth
MM
/
DD
/
YYYY
Age
Employment Status
Clear selection
Education
Highest School Grade Completed 0-12
High School Diploma, GED, HiSET or IEP Attendance/Completion Attained
Current School Status
Attending Any School
Clear selection
If Yes, School Name
Highest Education Level Completed Beyond High School (Check all that apply)
PUBLIC ASSISTANCE (Please check off all that apply. These circumstances will not prevent you from receiving services.)
PERSONAL CIRCUMSTANCE(S) (Please check off all that apply. These circumstances will not prevent you from receiving services.)
Family Size & Children
# of Family Members (Household)
How many children do you have in the following age groups:
Age 13 or younger
Ages 14 - 17
Do you need child care assistance?
Clear selection
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