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Why did you stop pursuing self-employment?

Have you served in the military? Yes ☐ No ☐ Date from:

Please provide additional information on service branch, responsibilities, trainings, and certifications.

Do you have volunteer experience? Yes ☐ No ☐ If yes, where did you volunteer and what did you do?

(I) EDUCATION/TRAINING Tell us about your education including the highest level of education you have achieved along with completion dates.

Tell us about any vocational training, certifications, occupational licenses, or college classes you have completed.

Tell us about your learning challenges or if you participated in special programs while attending school?

What types of training or formal education would you be interested in obtaining and why?

When and where would you like to attend post-secondary education or training?

(J) SUPPORT SYSTEM AND FAMILY SITUATION Do you have relatives and/or close friends in the area that you can contact in a time of need or for help? Yes ☐ No ☐ If yes, who are they and what is their relationship to you?

Emergency Contact:

How many children are currently living with you?

What are their ages?

Are you pregnant? Yes ☐ No ☐ If yes, due date:

Who do you consider to be your support system, the person/people you celebrate with, go to when you have a problem, or call when you want to talk?

What do you like to do in your spare time (hobbies, church, play with your children, read, watch TV, socialize, etc.)?

What programs have you worked with in the past (ex. Job coaching, Dept. of Aging and Rehabilitative Services (DARS), Community Service Board (CSB), etc.)? Describe the program and when you participated.

032-22-1090-01-eng

(E) FINANCIAL SITUATION Are you able to pay your monthly bills? ☐ Yes ☐ No Would you like budgeting assistance? ☐ Yes ☐ No List any debts, loans, past-due or unpaid bills, and court fines:

List your current expenses: Rent

Utilities

Phone/Cable

Page 676

Official source

Why did you stop pursuing self-employment?

Have you served in the military? Yes ☐ No ☐ Date from:

Please provide additional information on service branch, responsibilities, trainings, and certifications.

Do you have volunteer experience? Yes ☐ No ☐ If yes, where did you volunteer and what did you do?

(I) EDUCATION/TRAINING Tell us about your education including the highest level of education you have achieved along with completion dates.

Tell us about any vocational training, certifications, occupational licenses, or college classes you have completed.

Tell us about your learning challenges or if you participated in special programs while attending school?

What types of training or formal education would you be interested in obtaining and why?

When and where would you like to attend post-secondary education or training?

Emergency Contact:

How many children are currently living with you?

What are their ages?

Are you pregnant? Yes ☐ No ☐ If yes, due date:

Who do you consider to be your support system, the person/people you celebrate with, go to when you have a problem, or call when you want to talk?

What do you like to do in your spare time (hobbies, church, play with your children, read, watch TV, socialize, etc.)?

032-22-1090-01-eng

(E) FINANCIAL SITUATION Are you able to pay your monthly bills? ☐ Yes ☐ No Would you like budgeting assistance? ☐ Yes ☐ No List any debts, loans, past-due or unpaid bills, and court fines:

List your current expenses: Rent

Utilities

Phone/Cable