Wia 2000 Customer Self-Directed Assessment

Today’s Date: ______

JAS ID#: ______

PERSONAL INFORMATION Name: ______Date of birth: ______Address: ______City: ______Zip: ______Phone: ______Message Phone: ______Email: ______EDUCATION

Highest Grade Level or Degree completed: List all training Certificates: School Name: Program: Date Completed: School Name: Program: Date Completed:

EMPLOYMENT (Please provide a minimum of 7 years work history or previous three jobs)

1. Present or most recent employer name: ______City ______Your job title: ______Hours per week: ______Start date: ______End date: ______Ending wage: ______Reason for leaving: Laid off Fired Quit Other *If other, please explain: ______Brief job description/key job functions: ______

2. Employer name: ______City ______Your job title: ______Hours per week: ______Start date: ______End date: ______Ending wage: ______Reason for leaving: Laid off Fired Quit Other *If other, please explain: ______Brief job description/key job functions: ______

3. Employer name: ______City ______Your job title: ______Hours per week: ______Start date: ______End date: ______Ending wage: ______Reason for leaving: Laid off Fired Quit Other *If other, please explain: ______Brief job description/key job functions:

5/16/11 ______

4/15/09