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.