Network Up Application and Assessment
Please complete this form and submit a copy of your resume to Jill Beres, jberes@britepaths.org, or Fax 703-273-7171. Thank you for participating in Network Up!
Name: *
Your answer
Address: *
Your answer
Phone Numbers: *
Your answer
Email: *
Your answer
Date of Birth (optional):
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/
DD
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YYYY
Gender: *
Are you currently employed: *
If Yes, full or part time:
Monthly salary (indicate N/A if not applicable): *
Your answer
Place of employment (indicate N/A if not applicable): *
Your answer
Are you a veteran: *
Ethnic background: *
Number of dependent children and ages (indicate N/A if not applicable): *
Your answer
Annual household income (indicate N/A if not applicable): *
Your answer
Do you receive money from any of the following sources? Please check all that apply: *
Required
Does the Head of your household have health insurance: *
Housing type (question required by county grant) *
Family type (question required by county grant) *
Income level (question required by county grant) *
How did you hear about Network Up: *
Your answer
In order to qualify for Network Up, you must meet all of the following requirements. Please indicate that you meet these qualifications: *
Required
Work History (please list your current or most recent job including dates of employment; job title; and job duties) (indicate N/A if not applicable): *
Your answer
Work History (please list your previous job including dates of employment; job title; and job duties) (indicate N/A if not applicable): *
Your answer
Education History (check all that apply): *
Required
I have submitted or will submit a resume to Jill Beres, jberes@britepaths.org: *
Employment Goals -- What type of work do you want to do (job sector/industry/job title). Please be specific: *
Your answer
Employment Goals -- List any barriers to employment that you have faced and would like to overcome: *
Your answer
Employment Goals -- List any skills, volunteer experience, or interest/hobbies that could apply to your professional life: *
Your answer
Conditions / Limitations -- Do you have any physical limitations that may interfere with your ability to perform certain types of work? If No, indicate N/A; if Yes, please explain: *
Your answer
Do you have a Linkedin account: *
Do you have a professional network *
Approximately how many contacts are in your professional network now? *
Your answer
What steps have you taken to reach your employment goals: *
Your answer
How can a mentor best assist you (please check all that apply): *
Required
Please check each box to certify the following: *
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