CUSTOMER APPLICATION AND INFORMATION SURVEY - MassHire Berkshire Career Center

Do you need special accommodations: (Required)

Yes
No

Job Seeker ID (Required)

Don't have a job seeker ID? Register on MassHire JobQuest at Mass.gov/JobQuest to create one.

Name (Required)

First

Last

Phone (Required)

Email (Required)

Limiting English Speaking? (Required)

Yes
No

Family Status

Number of Dependents under 18

US Citizen: (Required)

Yes
No

Disability (Required)

Yes
No

Other Barriers (Required)

Public Assistance (Required)

Yes
No

Please indicate any Public Assistance below (Required)

Are you registered for Selective Service (Required)

Yes
No
N/A

If no, explain?

Have you served in the Military? (Required)

Yes
No

Branch

Start Date

Release Date

Type of Discharge

Did you participate in a foreign conflict? (Required)

Yes
No

Have you worked in seasonal or temporary farming in the last 12 months (Required)

Yes
No

High School Graduate GED/HiSET (Required)

Yes
No

College Graduate (Required)

Yes
No

Highest Grade of Education Completed (Required)

In School Currently? (Required)

Yes
No

What was the last school attended?

Most Recent Employer (Required)

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title at Most Recent Employer (Required)

Start Date

Release Date

Salary

Hours Per Week

Are you collecting Unemployment benefits (Required)

Yes
No

How many weeks?

Exhausted (Required)

Yes
No

When Claim Started?

Do you have a Recall Date? (Required)

Yes
No

Services

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

Signature

Clear Signature