The following screening assessment is used to review your eligibility and suitability for the ACE Program.

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* 1. First Name:

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* 2. Middle initial:

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* 3. Last Name:

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* 4. Full Social Security Number:

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* 5. Date of Birth:

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* 6. Physical Address:

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* 7. County of Residence:

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* 8. City:

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* 9. State:

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* 10. Zip code:

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* 11. Personal Email:

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* 12. Phone Number:

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* 13. Alternative Phone Number:

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* 14. Please choose the training program you are interested in: (Please visit our website for program descriptions)

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* 15. Have you registered in EmployFlorida.com?

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* 16. Are you a U.S. Citizen or legally authorized to work in the U.S.?

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* 17. All males born January 1, 1960 or later are required to register with Selective Service. If applicable, have you completed this registration? To check your registration please visit sss.gov.

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* 18. Do you consider yourself to have a disability?

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* 19. Are you in the military, an eligible veteran, or spouse of an eligible veteran?

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* 20. Are you currently Active Duty military spouse who is unemployed/underemployed?

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* 21. Are you currently working?

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* 22. Current rate of pay?

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* 23. How many hours do you work per week?

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* 24. Are you able to work full-time?

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* 25. Have you been convicted of a Felony or Misdemeanor?

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* 26. Specify year and location of conviction?

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* 27. Are you pregnant or have a dependent child?

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* 28. Do you currently reside in a homeless shelter or are you currently homeless?

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* 29. Do you have a high school diploma?

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* 30. Do you currently receive or are a member of a household family that receives Food stamps or received Food stamps during the previous six months?

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* 31. Are you currently receiving TANF/Cash assistance?

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* 32. Are you currently in foster care or aged out of  foster care?

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* 33. What is your family size? (This includes the total number of people in your family= all individuals in your household related by blood, marriage or court decree.)

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* 34. What is your total annualized household income before taxes? (Family income = all those living in a household related by blood, marriage or court decree.)

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* 35. Type of income? (Please select all that apply)

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* 36. Do you use tobacco products, such as cigarettes, cigars, or chewable tobacco?

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* 37. If yes to question 35, would you like information on free products and support to help you quit smoking?

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