NJ Endures Intake Form

Individuals with Disability:
Yes     No   Choose not to disclose
[If Yes, please provide this information on Form D, which is kept confidential: Type of Disability: Hearing; Vision; Mental; Mobility; Cognitive/I/DD; Learning; Chronic Health]          
  

Military Service:
Yes   No  Branch: See DVOP Checklist.
Campaign Veteran   National Guard  Active DutyTransitioning Vet   DischargeRetirement   Other Eligible   Active Service Dates (to/from):      
Service Disability:
Disabled   Not Disabled   Special Disabled   
Receiving Veteran's benefits or Assistance?   Yes   No 
If Yes, specify:     
Military Spouse - Are you:
Active Duty Service Member Spouse   Service Member Widow   Disabled Veteran Spouse If active duty spouse, has your income been affected by spouse's deployment?     Yes   No   

Work Week: Full-Time   Part-Time   Both   Not Seeking Employment at this Time   
Minimum Salary: $      Per      
Date Available to Work:      
Shift Preference: Willing to work any shift?   Yes   No   
If No, which shift(s):   1st   2nd     3rd   Split       
Employment Objective:      
Desired Job Title(s):            
Desired Employer(s):         
Acceptable Job Locations (check one):
5   10   25   50   100 miles from my Zip Code:              

Driver's License:   No   Yes   State:
Type:   CDL-A   CDL-B   CDL-C   Auto   Moped    
Endorsements:         Tank Vehicle   Motorcycle   School Bus   Doubles/Triples     Tank Hazards   Air Brakes    

I attest that the information provided is true and accurate any misrepresentation may be grounds for termination from program(s). I further understand that being determined eligible for services and/or training does not necessarily entitle me to service/training.