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Activate Business Mid North
1.
First Name
2.
Last Name
3.
Address
Address
Address 2
City/Town
State
Postal Code
Email Address
Phone Number
4.
Date of Birth
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
5.
Gender
Male
Female
6.
Are you Aboriginal or Torres Strait Islander
Yes
No
7.
Are you currently at School? Please note school students are not eligible for this program.
Yes
No
8.
Are you currently employed?
Yes
No
9.
If you are employed, please indicate your employment type
Full-time
Part-time
Casual
10.
If you are employed, please indicate the number of hours of paid employment per week
11.
Please provide your job seeker ID if you have one and know it
12.
Are you registered with an employment service provider?
Yes
No
13.
If yes, please provide details
Jobactive
Transition to work
ParentsNext
Disability Employment Services
14.
Which provider are you registered with?
Madec
Sureway
yourtown
Please specify
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)
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)
17.
Do you have a
Business
Hobby Business
Business idea
Please provide further information
18.
What are your reasons for wanting to be part of this program?
19.
How did you hear about the program?
Family member/ Friend
Employment service provider
Newspaper
Radio
Social media
Other (please specify)
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
