YOUTH PRE-APPLICATION

By answering these questions, I acknowledge the information I provide will be shared with AJC partners to assist with my needs.

Which American Job Center location is nearest to you? *

Date *

Full Name *

Last 4 digits of your Social Security Number *

Email Address

Home Phone Number (if applicable)

Cell Phone Number *

Parent or Guardian Phone number *

Date of Birth *

Age

Gender *

Ethnicity *

Registered for Selective Service? (Males only- 18 years and over)

From where are you accessing this website? *

How would you prefer for us to reach you? (select all that apply)

Call

Text

If you choose text, who is your cell phone carrier?

Have you registered on Jobs4TN.gov? Not Selected Yes No

What is your desired occupation?

Please describe your desired career pathway and goals for employment and/or education?

Educational Status *

Did you drop out of High School? Not Selected Yes No

Education Level Not Selected High School Diploma / High School Equivalency Test (HiSET), formerly GED Less than High School Diploma Some College / previous training Currently enrolled in college Associate Degree Bachelors Degree Masters Degree Doctoroal Degree

Are you a first generation college student? Not Selected Yes No

Do you need assistance with completing dual enrollment courses or credit recovery to complete secondary school? Not Selected Yes No

Do you need assistance with tuition to complete an educational program? Not Selected Yes No

Have you been suspended from school in the last 12 calendar months? Not Selected Yes No

Do you qualify for free and reduced lunch? Not Selected Yes No

Which best describes your current employment status?

Employment Status Not Selected Full time Part time (PT is less that 30 hrs/wk or considered PT by your employer) Self-employed Employed, but received termination notice from employer / military Not Employed, but available for work and looking for work Not Employed, and have not actively been looking for work

Are you enrolled or planning to enroll in school or training? Not Selected Yes No

Do you have a disability? (Physical, mental, intellectual, developmental, etc) Not Selected Yes No

Do you have reliable transportation? Not Selected Yes No

What type of transportation do you typically use? (i.e; personal car, public transit)

Are you pregnant or parenting youth? Parenting Youth Pregnant Not applicable

Household size? (total number living in household) *

Does your household receive receive SNAP benefits? Not Selected Yes No

Household income (select range): *

Have currently incarcerated parents? Not Selected Yes No

Do you have a stable place to live? Not Selected Yes No

Have you ever been or are you currently in the foster care system? Not Selected Yes No

Is English your second language? Not Selected Yes No

Have you been involved in the justice system? (Note: this will not prevent you from receiving assistance) Not Selected Yes No

Do you have barriers to employment/education (i.e., what is preventing you from getting a job or education?) - if yes, please check all that apply: Not Selected Yes No

No work experience

Need training

Disability

No reliable transportation

Need better interview/communications skills

Need proper interview/work clothes

Legal issues/restrictions

Need childcare

Language barrier

Lack of computer skills/no email address

Difficulty accessing documents (i.e., birth certificate, license)

No working internet access

No working telephone

Lack of stable housing

Do you have poor work history, no work history, or have been fired from a job in the last 6 months? Not Selected Yes No

Are you receiving or have you received assistance from the following in the last 6 months? (Please check all that apply) Not Selected Yes No

SNAP (currently receiving)

SNAP (within the last 6 months)

Supplemental Security Income (SSI)

TANF

None

What else can we help you with?

How did you hear about us?

To prove you are a human, please tell us what is 1+3?