GENERAL INFORMATION
First Name (required)       Last Name (required)

Middle Initial/Name (required)

Email (required)       Phone Number (required)

Street Address (required)       City (required)

Zip Code (required)       State (required) —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

County (required)

Are you working with an employment provider agency? (required) NoYes

- If yes, agency name:   Contact person at agency

Phone Number       Email

Do you have an active case with Vocational Rehabilitation? (required) NoYes

- If yes, counselor name:

Phone Number       Email

Do you have an active case with DMH/Regional Center? (required) NoI'm not sureYes  

- If yes, case manager name:

Phone Number       Email

EMPLOYMENT INFORMATION
Please upload a résumé that includes all prior work history, volunteering and education. (Please use .pdf, .doc or .docx file formats.)

What is your job goal?

What hours are you available to train or work? If you have open availability, please write "OPEN" in the boxes. (required)
Monday:
Start Time     End Time
Tuesday:
Start Time     End Time
Wednesday:
Start Time     End Time
Thursday:
Start Time     End Time
Friday:
Start Time     End Time

How do you plan to get to and from training or work? (required)
I will drive my own car to/from work.I have someone who will take me to/from work reliably.I will take Call-A-Ride to/from work.I will take a bus or public transit to/from work.I don’t know how I will get to/from work.

Many employers participating with Talent Connect require trainees and employees to undergo a background screen.
Do you have a criminal history, prior convictions, or findings of abuse/neglect? (required)
No, I have no criminal history or findings of abuse/neglect.Yes, I have criminal history that could show up on a background screen.
If you answered yes to the above question, please provide information below about your criminal history:
(Please include the year or date probation/parole will end)

If you were asked to take a drug screen today, would your results be free of any illegal substances? (required)
Yes, I’d pass.No, I would not pass.I don’t know if I would pass today.

Have you ever been terminated from a job? (required)
No, I have never been terminated from a job.Yes, I have been terminated from at least one job.
If you answered yes to the above question, please provide information about any jobs from which you were fired.

I certify that the information provided in this application has been completed truthfully to the best of my ability.