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VIRGINIA DEPARTMENT OF SOCIAL SERVICES SNAP EMPLOYMENT & TRAINING (SNAPET) PRE-ASSESSMENT FORM

Please complete this form and mail it back to us in the enclosed envelope by .

A. General Information/Education

YOUR FULL NAME:

ADDRESS:

PHONE: LAST GRADE COMPLETED ARE YOU ABLE TO READ ENGLISH? YES NO

LIST ANY TRAINING, SKILLS OR SPECIAL SCHOOLING YOU HAVE TAKEN:

DID YOU COMPLETE A COURSE? DID YOU RECEIVE A CERTIFICATE? WHEN?

B. Employment

ARE YOU WORKING NOW? YES NO IF NO, DO YOU EXPECT TO BE WORKING SOON? YES NO

PLEASE TELL US ABOUT YOUR CURRENT JOB OR LAST JOB:

EMPLOYER’S NAME:

YOUR JOB TITLE: DATE BEGAN: DATE LEFT:

YOUR DUTIES:

PAY PER HOUR: HOURS PER WEEK:

WHAT OTHER TYPES OF JOBS HAVE YOU HELD IN THE PAST?

WHAT TYPE OF EMPLOYMENT ARE YOU INTERESTED IN?

C. Employment/Training Needs:

IS THERE ANYTHING WE NEED TO KNOW IN HELPING YOU FIND EMPLOYMENT? (CHECK ALL THAT APPLY TO YOU)

LACK OF SKILLS OR TRAINING LACK OF CHILD CARE

NEED EYEGLASSES MEDICAL PROBLEMNS

NO JOBS AVAILABLE

LACK OF TRANSPORTATION CANNOT READ FAMILY PROBLEMS

DID NOT FINISH HIGH SCHOOL LANGUAGE PROBLEMS

OTHER

PLEASE GIVE DETAILS FOR ANY ITEMS YOU HAVE CHECKED:

IS THERE ANYTHING ELSE WE NEED TO KNOW ABOUT YOU OR YOUR SITUATION?

YOUR SIGNATURE:

DATE:

* PLEASE RETURN THIS FORM IN THE ENCLOSED STAMPED ENVELOPE TODAY *

AGENCY USE ONLY

Assigned to Pending Inactive Active (specify)

Reason:

Begin Date: End Date: Worker #: Date:

032-02-014/2 (10/09)