CUSTOMER APPLICATION AND INFORMATION SURVEY - MassHire Berkshire Career Center

Do you need special accommodations: *

Yes
No

Job Seeker ID *

Name *

First

Last

Phone *

Email *

Limiting English Speaking? *

Yes
No

Family Status

Number of Dependents under 18

US Citizen: *

Yes
No

Disability *

Yes
No

Other Barriers

Public Assistance *

Yes
No

Please indicate any Public Assistance below *

Are you registered for Selective Service *

Yes
No
N/A

If no, explain?

Have you served in the Military? *

Yes
No

Branch

Start Date

Release Date

Type of Discharge

Did you participate in a foreign conflict? *

Yes
No

Are you a disabled veteran? *

Yes
No

High School Graduate GED/HiSET *

Yes
No

College Graduate *

Yes
No

Highest Grade of Education Completed *

In School Currently? *

Yes
No

What was the last school attended?

Most Recent Employer *

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title at Most Recent Employer *

Start Date//

Release Date//

Salary

Hours Per Week

Are you collecting Unemployment benefits *

Yes
No

How many weeks?

Exhausted

Yes
No

When Claim Started?

Do you have a Recall Date?

Yes
No

Services

Please Check Off(✓) Any Services/Workshops You May Be Interested In *

Signature