Initial Application General Customer Name: ______Birth Date: ______SS#: ______
Address: ______Zip Code: ______
Phone Number: ______Email: ______
Do you receive Social Disability benefits? SSI or SSDI Are you a Veteran? ______
Is it difficult for you to cover your monthly expenses? ______Do have a bank account? ______
What are your financial goals? 1)______2)______3)______
Work Information Do you have a Resume? Yes_____ No _____ Do you need assistance with your resume? Yes _____ No _____ Are you registered in Employ Florida ? Yes _____ No_____ Is your resume active in EFM? Yes _____ No _____ Rate your computer skills (1 – 10 highest):______Have you worked in the last 18 months? Yes ____ No ____ Are you currently receiving Unemployment Compensation? Yes _____ No _____ Number of months: ______Are you currently receiving Food Stamp assistance? Yes ______No ______Enrolled in SNAP E&T______Other Service/Assistance Providers used: ______
Check all that apply below:
Barriers to Employment Strengths No High School Diploma/GED Post Secondary Education Limited Work History/Experience Recent Work Experience No or Limited Transportation Communication Skills Clean driver’s license - Yes / No Adaptive Limited Job Retention Analytical/ Formulating Lack of work Clothing Evaluate/ Examine /Explain Legal Issues/Ex-Offender Creative Thinking /Implementation Health/Mental Health Disability Managing/ Monitoring/ Mentoring Physical Disability Planning /Presenting Substance Use Problem Solving Domestic Violence Issues Teaching/ Trouble Shooting Background Issues Tracking /Details Housing/Homeless Writing No Childcare Coordinating / Compiling/ Checking Other (such as Sensory or Learning Disability) -
Education Goal:
Highest Level of Education: ____ High School ____ Certificate ____ Associate ____Bachelor’s ____ Master’s
List Certifications/Degrees: ______
Currently enrolled or planning on enrolling in school? Yes _____ No _____
What Program: ______Training Provider: ______Anticipated Start Date: _____/_____/_____ Anticipated End Date: _____/_____/_____ 1 PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one individual from another, and for tracking and reporting purposes. An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711. 1/23/2015 Employment Goal:
What was your last job? ______Last employment date ______
Currently employed? Yes No Hours/Week: Wage:
Short Term Goal (3-12 mo.) Job Title: ______Hours/Week: ______Wage: ______
Long Term Goal (3-5 yrs.) Job Title: ______Hours/Week: ______Wage: ______
SKILLS: (Please check off the skills/knowledge you currently possess)
OFFICE COMPUTER ____Typing WPM ____Bookkeeping ____Networking ____Reception ____Data Entry ____ Help Desk ____Word ____Excel ____Internet ____Outlook ____PowerPoint ____Programming ____Customer Service
RETAIL/FOOD SERVICE/HOSPITALITY OTHER PROFESSIONAL SKILLS ____Cashier ____Food Prep. ____Security ____Server ____Housekeeping ____Management ____Sales ____Education
Action Plan:
Employment Objectives: Planned Completion
To obtain training in a demand occupation to become self sufficient.
To obtain a Part time Job as a ______
To obtain a Full time job as a ______
To attend Job Center Resume Workshop to assist in Job Search:
I have attended or assigned to attend the Disability Orientation including basic work incentives information, phone numbers, the SSA Red Book and have been encouraged to use this information to get answers to specific questions about going back to work and how it will affect my benefits. *Remember you MUST report wages directly to Social Security!
Customer Signature: ______Date: ______
Referred to: Smart Money____ SNAP/FS ____ VR ____ VITA/My Free Taxes ____ WIA ____ IDA ____
Other: ______
Notes:
For your Ticket to Work appointment for please complete and bring the following. Employ Florida Marketplace www.employflorida.com - Register or update your current information and complete the Resume section and the Virtual Recruiter. Driver License Social Security Card Current resume - If you do not have one, please sign up for a resume workshop. Interest Inventory Complete Florida E-choices Assessment: 1. Go online to https://secure.flchoices.org/ 2. Click on the adult version of the “Career Planning” 3. Select the assessment, “Interest Profiler” and complete, you may complete additional assessments listed (Career Cluster, Basic Skills Survey, Transferable Skills or Work Values Sorter) 4. Print the results page and bring to you appointment or you may e-mail the results.
O-net Job Descriptions Locate 3 occupations/job titles that you are interested in pursuing 1. Go to www.onet.org 2. Click on find occupations 3. Locate 3 job titles that you are interested in pursuing and print
Bring copies of your assessment results and the job descriptions to you next meeting. ______Resources: Skills profiler: www.careerinfonet.org Research new careers: www.myskillsmyfuture.com Career exploration and information on numerous occupations: www.careeronestop.org Computer, reading or math skills training (free): GCF Learning Free www.gcflearnfree.org Social Security Administration and disability benefits: http://www.ssa.gov/work/ Ticket to Work Information: http://www.socialsecurity.gov/work/receivingbenefits.html CareerSource Pinellas: www.careersourcepinellas.com SNAP-Job search and transportation assistance: South County (727) 608-2500 or North County (727) 608-2428 Safelink - a service provider of free cell phones with 250 minutes. Bank On – Financial stabilisation programs TAX assistance : VITA, MyFreeTaxes, EITC Financial Education – Money Smart program is located on the Resource Area computers. Financial Workshop in the Tarpon office. To find affordable housing: www.FloridaHousingSearch.org or www.GoSection8.com
Job search engines for persons with disabilities Disabled Person: https://www.disabledperson.com/ Getting Hired: http://www.gettinghired.com/ Hire Disability Solutions: http://www.hireds.com/ One More Way: http://www.onemoreway.org/ Employer Assistance and Resource Network: http://askearn.org/ Ability Jobs: http://www.jobaccess.org/ Think Beyond the Label: http://thinkbeyondthelabel.com/ http://abilityJobs.com http://jobs.disabilityscoop.com https://abilitieswork.employflorida.com
To schedule an appointment to meet with a Disability Specialist: [email protected], (727) 608-2552
3 PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one individual from another, and for tracking and reporting purposes. An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711. 1/23/2015