First Name *

Last Name *

Phone Number (Area Code First) *

Street Address *

Zip Code *

What department do you work in at Goodwill? *

How long have you worked for Goodwill? *

Are you currently receiving health benefits through Goodwill? *

Are you currently taking advantage of your 401K benefit? *

What computer skills do you believe you are skilled at? *

Do you have permanent housing? *

Which of the following applies to your housing situation? *

Do you own a vehicle that brings you to and from work? *

Which of the following applies to your transportation situation. *

Do you have enough food to eat? *

Which of the following applies to your food situation *

Do you have adequate childcare? *

Which of the following applies to your childcare situation *

Are you able to provide yourself with the necessary clothing for work? (Uniforms) *

Which of the following applies to your clothing situation *

Have you earned a high school diploma or equivalent? *

What is your highest level of achieved education so far? *

Do you have a bank account? *

What is your current financial situation? (check all that apply) *

Are mental health services important to you for either issues of diagnosed/undiagnosed mental health or substance abuse or addiction counseling? *

What mental health services could you benefit from? *

Do you need any legal aid services *

How could you benefit from legal services? *

Have you been diagnosed with a disability? *

What disability services have you used? *

IF you do not have healthcare coverage through Goodwill, do you have it through another source? *

What is your current healthcare situation? *

Do you have access to the following: (Check all that apply) *

Do you have a drivers license in good standing? *

If you do not have a drivers license, what is in your way? *

Are you affiliated with a tribe? If so, which one? *

Signature (type full name) *