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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number(Required)Secondary Phone NumberEmail(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 Select AllI 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 Select AllEMPLOYMENT Deciding on a career Preparing a resume Filling out an application Preparing for an interview Finding a job Select AllPERSONAL 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 Select AllLEGAL SERVICES Expunging records Sealing criminal records Getting a petition for "Certificate of Good Conduct" Select AllAUTHORIZATION 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 InstructionsHow 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: PhoneThis field is for validation purposes and should be left unchanged.