WORK HISTORY / HISTORIA DE TRABAJO |
| Are you working now?/ Estás trabajando ahora? No Yes |
| Where?/Donde? Hours per week/ Horas por semana: Hourly Wage/ Pago por Hora: |
| Is your spouse employed?/ Está su pareja trabajando? No Yes |
| Where?/Donde? Hours per week/ Horas por semana: Hourly Wage/ Pago por Hora: |
| If unemployed, did you receive a termination or layoff notice?/ Si está desempleado, recibió su carta de terminación? |
| No Yes Date received/ Fecha en que recibió la carta: |
| Check your reemployment insurance status/ Verifique el estatus de su seguro de desempleo: |
| Eligible Claimant / Demandante Eligible Not Eligible / No Eligible Claim Exhausted / Demanda Agotada |
| What have you been doing since your last job?/ Qué ha estado hacienda desde que dejo su último trabajo? |
| What type of work are you looking for?/ Qué tipo de trabajo busca? |
| LIST YOUR WORK EXPERIENCE COMPLETELY STARTING WITH YOUR PRESENT OR MOST RECENT JOB LISTE SU EXPERIENCIA DE TRABAJO, COMENZANDO CON EL MAS RECIENTE |
| Company Name/Nombre de la Compañía: | Address/Dirección: |
| Job Title/Cargo: | Supervisor: |
| Job Duties/Deberes de Trabajo: |
| Reason for leaving/ Razón del porque lo dejaste: |
| Dates of Employment/
Tiempo de Empleo | Total Time Employed/ Total del Tiempo Trabajando | Hours per Week/ Horas por Semana | Starting Salary/ Salario Inicial | Ending Salary/ Salario Final |
| From/De: | To/Hasta: | Years/Años: | Months/Meses: | | $ | $ |
| Company Name/Nombre de la Compañía | Address/Dirección: |
| Job Title/Cargo: | Supervisor: |
| Job Duties/Deberes de Trabajo: |
| Reason for leaving/ Razón del porque lo dejaste: |
| Dates of Employment/
Tiempo de Empleo | Total Time Employed/ Total del Tiempo Trabajando | Hours per Week/ Horas por Semana | Starting Salary/ Salario Inicial | Ending Salary/ Salario Final |
| From/De: | To/Hasta: | Years/Años: | Months/Meses: | | $ | $ |
| Company Name/Nombre de la Compañía | Address/Dirección: |
| Job Title/Cargo: | Supervisor: |
| Job Duties/Deberes de Trabajo: |
| Reason for leaving/ Razón del porque lo dejaste: |
| Dates of Employment/
Tiempo de Empleo | Total Time Employed/ Total del Tiempo Trabajando | Hours per Week/ Horas por Semana | Starting Salary/ Salario Inicial | Ending Salary/ Salario Final |
| From/De: | To/Hasta: | Years/Años: | Months/Meses: | | $ | $ |
| Expain any gaps in your work history/ Explique que hacia mientras no tenía trabajo: |
| MILITARY SERVICE / SERVICIO MILITAR |
| Are you a veteran?/ Eres un veterano? No Yes | Did you receive an honorable discharge?/
Recibió un descargo honorable? No Yes | Date of Enlistment/ Fecha de Alistamiento | Date of Discharge/ Fecha de Terminación | Branco of Service/ Rama de Servicio | Rank/
Rango |
| Were you released for a service connected diability?/ Terminó su servicio por una discapacidad en el deber? No Yes | Are you eligible for veteran’s employment or training benefits?/
Es usted elegible para los beneficios del empleo o del entrenamiento de los veteranos? No Yes |
| Military Schools/Escuelas Militares: | Military Job Duties/Deberes Militares que Realizó: |
| LEGAL |
| Do you have a pending court appearance?/ Tienes alguna corte pendiente? |
| Have you ever been convicted of or are you now under charges for any offense against the law other than traffic violations?/ Has sido convicto o tienes cargos por alguna ofensa contra la ley que no incluye violaciones de tráfico? |
| List below all convictions except juvenile (Under 18)/ Liste abajo todas las conviciones excepto juveníles (Menos que 18) |
| Date/Fecha | City & State/Ciudad y Estado | Offense/Ofensa | Result (Fine, stay, incarceration, etc.)/ Resultado |
| | | | |
| | | | |
| | | | |
| ECONOMIC STATUS / ESTATUS ECONOMICO |
| Do you rely on someone else for more than half of your support?/ Usted depende de otra persona, por más del 50% de tu apoyo económico? |
| No Yes Explain/Explique: |
| Does anyone rely on you for support (for example, child support)?/ Alguien depende de usted por apoyo (por ejemplo, child support)? |
| No Yes Explain/Explique: |
| ARE YOU OR ANY OF YOUR FAMILY RECEIVING ANY OF THE FOLLOWING? USTED O ALGUIEN EN TU FAMILIA ESTA RECIBIENDO ALGUNO DE LOS SIGUIENTES? |
| Program/Programa | No | Yes | Monthly Amount/ Cantidad Mensual | Date Started/ Fecha de Inicio | Case Number/ Número de Caso |
| MFIP (Single Parent Family) | | | | | |
| MFIP (Two Parent Family) | | | | | |
| GA | | | | | |
| Refugee Assistance | | | | | |
| SSI | | | | | |
| Food Support | | | | | |
| Worker’s Compensation | | | | | |
| Reemployment Insurance | | | | | |
| Veteran’s Benefits | | | | | |
| Social Security Disability | | | | | |
| Social Security Retirement | | | | | |
| Social Security Survivors | | | | | |
| Pension (Specify) | | | | | |
| Medical Assistance | | | | | |
| Other (Specify) | | | | | |
| PLEASE READ BELOW BEFORE COMPLETING AND SUBMITTING THIS APPLICATION. West Metro Job Partners is a group of state, county, city and community based programs in Hennepin, Scott and Carver Counties. The partner agencies assess each applicant at intake to determine the person’s eligibility for services and to determine which services will help the applicant get a job and an increase in income. So that we can make the best possible assessment, we will be asking you to give us information about yourself. Except for your social security number, all of the information you will be asked to supply on our application form is necessary to complete our assessment. DATA PRIVACY NOTICE: West Metro staff use the information you give us to help you find employment and training. We put the information in a case file and a computer record keeping system. Agency staff can see the information in order to carry out their job duties. We use the information for your assessment and to develop an Employment Services plan and to gather information for reports and audits required by Federal and State agencies that provide the money to run our programs. Information on this form is private data. Only information directly related to helping you find employment will be shared with employers. Private information is available only to you and other West Metro Employment and Training Service Providers and local and state welfare agencies. You are not legally required to answer any of the questions. If you do not provide the information, or give us false information, program benefits may be denied or delayed. EQUAL OPPORTUNITY POLICY: We consider applicants without regard to race color, creed, religion, national origin, sex, marital status, disability, sexual orientation, or status with regard to public assistance. It is our policy to abide by all Federal, State, and local laws concerning discrimination. COMPLAINT AND APPEAL POLICY: If you feel that anyone in our office has treated you unfairly, you have the right to file a complaint. If you have been denied services, you have the right to file an appeal. If you wish to file a complaint or appeal, please see a staff member for assistance. The information I have provided on this application is true to the best of my knowledge. I have been made aware of and understand the Data Privacy Notice. I agree that the information on this form may be shared among West Metro Job Partner agencies in order to help me find employment or training. My consent begins on the date I sign this form and lasts for one year. _______________________________________________________________________ _______________________________________________ Applicant Signature/Firma de Aplicante Date/Fecha |
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