Attachment H Alternative Staffing Organization Program ASO to Partner Referral Form Participant Information: Name: Birth Date: Referral Date: CalJOBS Application #: Referral To: If Other, Please Specify: Participant is considered Job Phone Number: Alternate Phone Number: Ready: Email: Yes ☐ No☐ Gender: Social Security Number (Last Four Female ☐ Male☐ Digits): Participants considered Job Ready will be referred to the ASO Program. Others will be If Male, registered with Selective Veteran: referred to LA:RISE Service: Yes☐ No☐ Yes☐ No☐ Referring ASO Information: Agency Name: Phone Number: E-mail: Staff Name: Address: Services Needed (Please Check all that Apply): Support Services (Please Specify) On the Job Training Educational Assistance Training (Please Specify) Resume/Interview Workshops Job Placement Career Counseling Financial Literacy Advisement CalWORKS Housing Assistance CalFresh Other General Relief (GR) Medi-Cal Comments: Staff Name: ______________________ Staff Signature:______________________ (staff printed name) Date: _______________ Page 1 of 2 Partner Sites: DPSS – Pasadena Office Slawson AJCC 955 N Lake Ave, Richard N. Slawson Southeast Pasadena, CA 91104 Alhambra AJCC Occupation Center (626) 569-1399 2550 W. Main Street, Suite 101 5500 Rickenbacker Rd. Alhambra, CA 91801 Bell, CA 90201 DPSS – Pomona Office (626) 677-2600 (323) 729-6400 2040 W Holt Ave, Pomona, CA 91768 Antelope Valley Comprehensive Southeast L.A. Comprehensive (626) 569-1399 AJCC AJCC nd 1420 W. Avenue I 2677 Zoe Ave., 2 floor DPSS – Rancho Park Office Lancaster CA 93534 Huntington Park, CA 90255 11110 W Pico Blvd, (661) 945-5037 (323) 586-4700 Los Angeles, CA 90064 (866) 613-3777 Baldwin Park AJCC Veterans AJCC (Bob Hope Patriotic Hall) Baldwin Park Adult School, ACT DPSS – San Fernando Sub Office nd 1816 S. Figueroa Street. Center2 9188 Glenoaks Blvd, 4640 Maine Ave. Los Angeles, CA 90015 (213) 742-9560 Sun Valley, CA 91352 Baldwin Park, CA 91706 (626) 569-1399 (626) 856-4125 West Covina AJCC 933 S. Glendora Ave. East L.A./West San Gabriel West Covina, CA 91790 DPSS – San Gabriel Valley Office Valley Comprehensive AJCC 3352 Aerojet Ave, nd (626) 814-8234 5301 Whittier Blvd., 2 floor El Monte, CA 91731 Los Angeles, CA 90022 West Los Angeles AJCC (626) 569-1399 (323) 887-7122 5446 Sepulveda Blvd. Culver City, CA 90230 DPSS – Southwest Special Office East San Gabriel Valley (310) 652-6378 1819 Charlie Sifford Drive Comprehensive AJCC Los Angeles, CA 90047 14101 E. Nelson Avenue Willowbrook AJCC (323) 420-2918 La Puente, CA 91746 Willowbrook Library (626) 934-2801 5446 11737 Wilmington Ave. DPSS – South Central Office Los Angeles, CA 900059 10728 S Central Ave, Northeast San Fernando Valley (323) 564-5021 Los Angeles, CA 90059 AJCC (866) 613-3777 13420 Van Nuys Blvd. Ste 221 DPSS – Civic Center Office Pacoima, CA 91331 813 E 4th Pl, DPSS – South Special Office (818) 492-4052 Los Angeles, CA 90013 17600 B Santa Fe Ave. (213) 896-8890 East Rancho Dominguez, CA Palmdale AJCC 90221 38510 Sierra Highway DPSS – Glendale Office (310) 258-7400 Palmdale, CA 93550 4680 San Fernando Rd, (661) 265-7421 Glendale, CA 91204 DPSS – Wilshire Office (818) 701-8200 2415 W. 6th St. Pomona Valley Comprehensive Los Angeles, CA 90057 AJCC DPSS – Lancaster General Relief (310) 258-7400 264 East Monterey Avenue Sub Office Pomona, CA 91767 337 E. Ave. K-10 (909) 242-7999 Lancaster, CA 93535 (626) 569-1399 Santa Clarita AJCC 20730 Soledad Street DPSS – Metro East Office Santa Clarita, CA 91351 2855 E. Olympic Blvd. (661) 298-0152 Los Angeles, CA 90023 (626) 569-1399 South L.A. AJCC L.A. Southwest College, CTE DPSS – Metro Special Office Building Rm. 115 2707 S Grand Ave, 1600 W. Imperial Hwy. Los Angeles, CA 90007 Los Angeles, CA 90047 (866) 613-3777 (323) 241-5016 Page 2 of 2.