INTAKE FORM

Complete and submit the preliminary application form below to find out if you are eligible to receive American Job Center services:

TODAY'S DATE(Required)

Month

Day

Year

Legal Name(Required)

First Middle Last

Preferred Name/Pronoun

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Secondary Phone Number

Email(Required)

Enter Email Confirm Email

Date of Birth(Required)

Month

Day

Year

I live in the following County (check one):(Required)

Franklin

Jackson

Jefferson

Perry

Williamson

Other

Have you done farm work in the last 24 months, or are you a dependent of someone who has done farmwork in the last 24 months?(Required)

YES

NO

Are you a Veteran or a spouse of a Veteran?(Required)

YES

NO

Veteran (Section A)

Before completing Veteran Sections A, B, C, and D, shown below, please download and review the Veteran Eligibility Triage Form Definitions Document (PDF file, 276 KB).

Dates Served (From: — To:)

What was your Character of Service at discharge?

Honorable

Dishonorable

Other

Veteran (Section B)

If you check any of the boxes or answer "YES" to any of the questions in this section, you may be eligible for additional services, if desired.

Are you an eligible VETERAN who served between the years 1961-1975 and meets one of the following:

I served in the Republic of Vietnam between 2/28/1961 and 5/7/1975

I served (regardless of location) between 8/5/1964 and 5/7/1975

Are you an eligible VETERAN aged 18 to 24?

YES

NO

Are you a Transitioning Service Member who attended a Transition Assistance Program (TAP) workshop, and:

Are between the ages of 18-24 years old?

An active duty service member being involuntarily separated through a service reduction-in-force?

Do not meet career readiness standards (CRS)?

Are you a wounded, ill, or injured Service Member receiving care at a Warrior Transition Unit (WTU) or Military Treatment Facility (MTF)?

YES

NO

Are you a CAREGIVER for a wounded, ill, or injured Service Member receiving care at a WTU or MTF?

YES

NO

Veteran (Section C)

If you check any of the boxes in this section, please proceed to Section D and mark all applicable options.

Are you a VETERAN who:

Served on active duty for a period of MORE than 180 consecutive days (including Title 10 orders)?

Was discharged or released from active duty because of a service-connected disability?

Served in support of a conflict or campaign?

Was released from service under a Sole Survivorship discharge?

Are you the SPOUSE of a Veteran who:

Died of a service-connected disability, or while a disability was being evaluated?

Has been classified as a missing, captured, or detained Service Member?

Is 100% Total and Permanently Disabled?

Veteran (Section D)

If you check any of the boxes in the section below, you may be eligible for additional services, if desired.

Are you an eligible VETERAN or eligible SPOUSE (check all that apply):

Finishing my High School education

Improving my reading, writing, and/or math skills

Updating skills for a job

Enrolling in college

Educational expenses

Learning to speak English

I need help with the following (select all that apply):

EDUCATION

Finishing my High School education

Improving my reading, writing and/or math skills

Updating skills for a job

Enrolling in college

Educational expenses

Learning to speak English

EMPLOYMENT

Deciding on a career

Preparing a resume

Filling out an application

Preparing for an interview

Finding a job

PERSONAL BARRIERS

Temporary cash assistance (TANF, AABD)

Food Assistance (SNAP)

Medical assistance

Transportation to work and/or school

Disability services

Unemployment Insurance (UI)

Paying rent

Paying utility bills

LEGAL SERVICES

Expunging records

Sealing criminal records

Getting a petition for "Certificate of Good Conduct"

AUTHORIZATION TO RELEASE INFORMATION(Required)

I agree that American Job Center partners may share my information.

NOTE: Referrals will be sent within 24 hours.

Signature(Required)

By signing and/or submitting this form, customer has self-attested and acknowledges their status as listed in the sections above.

Comments/Special Instructions

How did you hear about us?(Required)

Facebook

Man-Tra-Con Website

Man-Tra-Con Marketing Flyer

Teacher

Friend or Family Member

Partner Organization

Other

Please list name of person or organization who recommended the American Job Center:

Did someone help you complete this form?(Required)

YES

NO

If YES, please list name of person or organization who helped you complete the form:

Name

This field is for validation purposes and should be left unchanged.