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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 SSN

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* 5. Date of Birth

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* 6. Physical Address

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* 7. City

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* 8. State

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* 9. Zip Code

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* 10. County of Residence

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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. Have you registered in EmployFlorida.com?

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

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

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

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* 18. Are you a veteran who has been terminated/laid off?

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* 19. Are you a veteran who was formerly self employed but is unemployed due to local economic conditions?

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* 20. Are you a previous member of the military who discharged from the Armed Forces with a discharge other than dishonorable?

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* 21. Are you separating or transitioning service member who has received a separation date or separation orders?

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* 22. If applicable, what is your planned separate date? Answer in MM/DD/YYYY format

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* 23. Are you within 30-60 days of your separation date?

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* 24. Have you recently separated from the Armed Forces?

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* 25. How long have you been separated?

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* 26. Are you the spouse of an active member of the military who was forced to leave his/her employment due to a change in Duty Station??

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* 27. Are you a dependent spouse of the Armed Forces on active duty whose family income is significantly reduced because of deployment?

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* 28. Are you the spouse of a Disabled Veteran who has passed away due to a Service Connected Condition?

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* 29. Are you currently working?

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* 30. If currently working, what's your current rate of ay?

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* 31. Hours worked per week?

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* 32. Are you able and willing to work full time?

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* 33. Have you received a notice of termination or layoff from your job?

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* 34. Have you applied for Unemployment benefits?

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* 35. Are you receiving unemployment benefits, or have you exhausted your unemployment benefits?

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* 36. Have you been convicted of a felony or misdemeanor?

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* 37. If applicable, specify year and location of conviction

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* 38. Are you currently receiving or have received SNAP/Food Stamps assistance in the last six months?

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* 39. Are you currently receiving TANF/Cash assistance thru DCF?

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* 40. What is your immediate family size? Note: this includes all members in your household related by blood, marriage or court decree

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* 41. What is your total annualized household income before taxes? Family income = all individuals in your household related by blood, marriage or court decree

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* 42. What types of Income did you or your family receive in the last 6 months?: (please select all applicable)

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* 43. What is the highest education level that you have attained?

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* 44. List of degrees/licenses/certifications that you’ve earned. Specify the year that you received each.

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