Activate Business Mid North Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Address Address Address 2 City/Town State Postal Code Email Address Phone Number Question Title * 4. Date of Birth Date Date Question Title * 5. Gender Male Female Question Title * 6. Are you Aboriginal or Torres Strait Islander Yes No Question Title * 7. Are you currently at School? Please note school students are not eligible for this program. Yes No Question Title * 8. Are you currently employed? Yes No Question Title * 9. If you are employed, please indicate your employment type Full-time Part-time Casual Question Title * 10. If you are employed, please indicate the number of hours of paid employment per week Question Title * 11. Please provide your job seeker ID if you have one and know it Question Title * 12. Are you registered with an employment service provider? Yes No Question Title * 13. If yes, please provide details Jobactive Transition to work ParentsNext Disability Employment Services Question Title * 14. Which provider are you registered with? Madec Sureway yourtown Please specify Question Title * 15. What is the highest level of education you have completed? Did not attend school Year 9 or lower Year 10 Year 11 Year 12/13 Trade/Certificate University Other (please specify) Question Title * 16. What was your main activity before registering for this project? Working Studying Volunteering Not actively seeking work Running a business Unemployed and looking for work less than 3 months Unemployed and looking for work for 3-6 months Unemployed and looking for work for 6-12 months Unemployed and looking for work for over 12 months Other (please specify) Question Title * 17. Do you have a Business Hobby Business Business idea Please provide further information Question Title * 18. What are your reasons for wanting to be part of this program? Question Title * 19. How did you hear about the program? Family member/ Friend Employment service provider Newspaper Radio Social media Other (please specify) Question Title * 20. If you are accepted onto the program, are you able to attend the one hour business coaching sessions (once a week for 4 weeks) in Clare? Yes No Done
