Employment Connection Center Intake Form Step 1 of 5 20% Contact Information*requiredName* First Middle Last Address* Street Address City State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Cell Phone* Email* Enter Email Confirm 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 American Asian Hispanic Mixed Native American Pacific Islander White What is your gender:* Male Female What is your marital status?* Single Married Separated Divorced Widow/er What is your citizenship?* United States Canada Mexico Are you a legal resident?* Yes No Are you disabled?* Yes No Do you have documentation to prove you are eligible to work?* Yes No What is your employment status?* Employed FT Employed PT Seasonal Unemployed What 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?* Yes No Are you a Military Veteran?* Yes No Are you a family member of a Veteran or Active Military personnel?* Yes No How 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 School High School Diploma or GED Some College Associate's Degree Bachelor's Degree Master's Degree or Higher Trade School or Certificate Transportation 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 StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 Employers Kennewick Community Services Benton & Franklin Counties Therapeutic Court Tri 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.Verbal Written Electronic Fax I 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* Reset signature Signature locked. Reset to sign again Date CAPTCHA