(Customized Form)

Question Title

* 1. Are you registered with the Virginia Workforce Connection?

Question Title

* 2. Your Gender:

Question Title

* 3. Date of Birth: (Please enter the two digit month, two digit day and four digit year)

Date

Question Title

* 4. Last 4 Social Security #:

Question Title

* 5. Are you authorized to work in the US?

Question Title

* 6. Your Contact Information:
(Please provide your full information.) 

Question Title

* 7. Registered for Selective Service:

Question Title

* 8. Citizenship Status:

Question Title

* 9. Do you wish to disclose a disability?  
Providing this information is optional and refusal to provide disability information will not subject you to any adverse treatment. Information regarding your disability status will be kept confidential as provided by law and will be used only in accordance with the law. Please note that for some programs, the information is needed to determine eligibility. Note too that you may be eligible for additional support services and programs if you have a disability.

Question Title

* 10. Are you currently attending school?

Question Title

* 11. What is the highest education level achieved?

Question Title

* 12. Security Clearance Status:

Question Title

* 13. Are you currently employed?

Question Title

* 14. Are you currently looking for work?

Question Title

* 15. Have you done any farm work or migrant food processing in the past 12 months?

Question Title

* 16. Have you received a notice of termination or layoff from your employer?

Question Title

* 17. Is English your primary language?

Question Title

* 18. Are you Hispanic or Latino?

Question Title

* 19. Race, select all that apply?

Question Title

* 20. Position Held/Desired

Question Title

* 21. What are your other jobs/skills?

Question Title

* 22. Are you the only wage earner in your home?

Question Title

* 23. Do you plan to seek reemployment?

Question Title

* 24. Do you plan to retire at this time?

Question Title

* 25. Will you seek employment in the same line of work?

Question Title

* 26. Are you willing to relocate?

Question Title

* 27. Miles you are willing to commute to work?

Question Title

* 28. What is your required pay range?

Question Title

* 29. Please list number of years of college/technical school and type of training or degree.

Question Title

* 30. Do you have other credentials?

Question Title

* 31. Would you be willing to commit to training that will assist in your future employment?

Question Title

* 32. What schedule would be best for training?

Question Title

* 33. What obstacles to training do you perceive for yourself such as childcare or internet?

Question Title

* 34. If arranged, would you be interested in attending a Hiring Event or Job Fair?

Question Title

* 35. Please indicate the area(s) of your career interests.

Question Title

* 36. What additional education or training would help you in your job search?

Question Title

* 37. What types of workshops would you attend if offered at a convenient location?

Question Title

* 38. Indicate any other assistance or services you would be interested in receiving.

Question Title

* 39. Are you a caregiver of a spouse or family member to a member of the armed forces who is wounded, ill or injured and receiving treatment in a military facility or war transition unit?

Question Title

* 40. Are you a member of the armed forces who is wounded, ill or injured and receiving treatment in a military facility or war transition unit?

Question Title

* 41. Are you currently in the military, a veteran or the spouse of a veteran?

Question Title

* 42. Are you a Spouse/Dependent of someone in active-duty military service, National Guard, or Reserves who is currently activated?

Question Title

* 43. Are you the spouse of a veteran who has total service connected disability, Missing in Action, captured in the line of duty by a hostile force, is a Prisoner of War or who died from a service connected disability?

Question Title

* 44. Are you within 24 months of retirement or months of discharge from the military?

Question Title

* 45. Have you served on active duty in the armed force and were discharged or released from such service under conditions other than dishonorable?

Question Title

* 46. First Active Duty Begin Date: (If you never served write N/A)

Question Title

* 47. First Active Duty End Date: (If you never served write N/A)

Question Title

* 48. Did you serve in the Republic of Vietnam anytime during 2/28/1961 and 05/07/1975?

Question Title

* 49. Received/Eligible for Military Campaign:

Question Title

* 50. Branch of Service:

Question Title

* 51. Are you active in the Military Reserves?

Question Title

* 52. Most recent character of service:

Virginia Employment Commission is an Equal Opportunity Employer/Program.  Auxiliary Aids and services are available upon request to individuals with disabilities.  TDD/TTY:  1-800-828-1120.
The Rapid Response Layoff Service Program is wholly funded with a $2,000,000 subaward to the Virginia Employment Commission by the Virginia Community Colleges System of the federal U.S. Department of Labor Employment and Training Administration Workforce Innovation and Opportunity Act (WIOA) funds (Award #AA-30941-17-55-A-51). One Hundred percent (100%) of the cost of this program is funded by federal funds.

T