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

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* 16. Are you a US 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 selective service register. Are you registered for Selective Service? 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 a veteran who has been terminated/laid off?

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

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* 21. Are you a previous member of the Armed Forces whose discharge
status is other than “dishonorable”?

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* 22. Are you a separating or transitioning service member who has
received an approved separation date?

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* 23. If applicable, what is your approved separation date? (Date format:
MM/DD/YYYY)

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* 24. Are you the spouse of an active duty service member and have
been forced to leave your job due to a change in duty? (applies to service
members on active orders)

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* 25. Are you a spouse of an active duty member of the Armed Forces
and your income has been significantly reduced due to change in duty
station? (applies to service members on active orders)

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

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* 27. Are you currently working?

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* 28. If currently working, what's your current rate of pay?

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

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

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* 31. Have you applied for unemployment benefits?

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

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

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* 34. If applicable, specify year and location of conviction:

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

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* 36. Are you currently receiving TANF/Cash assistance through DCF?

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* 37. 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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* 38. 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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* 39. What profession are you interested in?

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