Employment Connection Center Application Step 1 of 5 20% Contact Information*requiredName* First Middle Last Address* Street Address City State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Cell Phone*Email* Date of Birth* Background Information*requiredHow can we help you today?*Please circle all that apply Job Search / Leads Interview Skills Mock Interview Community Resources Computer Assistance Resume / Cover Letter Assistance Other Please explain:What is your ethnicity:*African AmericanAsianHispanicMixedNative AmericanPacific IslanderWhiteWhat is your gender:*MaleFemaleWhat is your marital status?*SingleMarriedSeparatedDivorcedWidow/erWhat is your citizenship?*United StatesCanadaMexicoAre you a legal resident?*YesNoAre you disabled?*YesNoDo you have documentation to prove you are eligible to work?*YesNoWhat is your employment status?*Employed FTEmployed PTSeasonalUnemployedWhat is your PRIMARY language?*Employment Barriers:* None Homeless Illiterate Criminal Background Lack GED / HS Diploma Limited Work History Lack of Transportation Computer Illiterate Other Please circle all that applyOther:If you receive TANF (Cash Assistance), would you like information about other Goodwill programs that may be available to you?*YesNoAre you a Military Veteran?*YesNoAre you a family member of a Veteran or Active Military personnel?*YesNoHow did you hear about us?Please check all that apply Work Release Goodwill Website Goodwill Store Ad or Associate WorkSource DSHS DVR AARP TCUG Mission TV/Radio Advertisement Friend/Family Division of Child Support Other Other: Emergency Contact CardBy completing the Emergency Contact Information, you are granting permission for Goodwill Industries of the Columbia to contact the following persons in case of emergency.Contact #1 Name*Relationship*Primary Phone #:*Alternative Phone #:Contact #2 Name*Relationship*Primary Phone #:*Alternative Phone #: Education & ExperienceWhat is your level of education?Some High SchoolHigh School Diploma or GEDSome CollegeAssociate's DegreeBachelor's DegreeMaster's Degree or HigherTrade School or CertificateTransportation Status: Own Vehicle Paratransit Public Transit Relies on Others Other Please state longest position held:Dates (Mo/Yr):Please state most recent position held:Dates (Mo/Yr):Please identify industries in which you are interested in working. Specify the positions you are qualified for:Labor/Warehouse/Landscaping (LWA) Labor/Warehouse/Landscaping (LWA) Position:Customer Service/Retail/Cashier (CSR) Customer Service/Retail/Cashier (CSR) Position:Childcare/Education (CE) Childcare/Education (CE) Position:Clerical/Receptionist/Front Desk (CO) Clerical/Receptionist/Front Desk (CO) Position:Medical/Dental/Caregiving (MD) Medical/Dental/Caregiving (MD) Position:Cook/Food Prep/Server/Host (R) Cook/Food Prep/Server/Host (R) Position:Janitorial/Housekeeping/ Building Maintenance (JHB) Janitorial/Housekeeping/ Building Maintenance (JHB) Position:Transportation/Delivery/CDL/Automotive (TDA) Transportation/Delivery/CDL/Automotive (TDA) Position:Other Other Position: Consent For Mutual Exchange of InformationName* First Middle Last Address* Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Goodwill is seeking your consent to communicate with the following entities regarding items as they relate to your ability to locate, obtain, or maintain employment. Please INITIAL all that apply.Current and Potential EmployersKennewick Community ServicesBenton & Franklin Counties Therapeutic CourtTri City Union Gospel Mission (TCUGM)Department of Corrections (DOC)Division of Child Support (DCS)Mental Health Court Please INITIAL all methods in which you will allow Goodwill to make contact with the above mentioned agencies.VerbalWrittenElectronicFaxI authorize the mutual exchange of the above listed information or record for the purpose of facilitating my employment goals. It is understood that the information provided above and obtained through this contacted will be treated with the strictest confidence. This release will be in effect for one year from the date signed, unless terminated in writing earlier by myself.Participant Signature*Date