Mercer Co. Path Forward

Name* This field is required.

First Name

Last Name

Email* This field is required.

Phone Number* This field is required.

Please enter a valid phone number.

Physical Address* This field is required.Enter the address where you are currently living.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Mailing Address* This field is required.If your permanent address is different from where you are currently living, pIease input that address here. If your mailing address and physical address are the same, indicate "Same As Above" in the Street Address box.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Date of Birth* This field is required.

Gender* This field is required.

Female

Male

Non-Binary

Prefer not to disclose

Race* This field is required.

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

Other

Educational Background* This field is required.Select the highest level of education completed.

Elementary School

High School Diploma

Some College

College Degree

Vocational Training

Skills and InterestsBriefly describe your personal skills and interests to help us better serve you.

Language ProficiencyList all languages spoken fluently.

Employment History

Most Recent Employer

Previous Employer

Preferred Employment Type

Full-Time

Part-Time

Temporary

Contract

Preferred Industry or Job Type

First Choice

Second Choice

Third Choice

Please specify type not listed above.

Please specify type not listed.

Are you currently undergoing a re-entry program?

YESNO

Legal Status

Describe any legal restrictions.

Criminal BackgroundList details of prior convictions, dates and types of offenses, and rehabilitation efforts taken.

Do you have health insurance?

YESNO

Do you have any medical conditions that may affect employment?Our goal is to support your entry into the workforce. This information will help us provide resources and information about your rights as an employee. Your information is held to the strictest confidentiality standards.

Describe any applicable conditions

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone #

Additional Comments/QuestionsPlease provide any additional information you would like to share.

How did you hear about this program?

Other Referral Source

Mercer Co. Path Forward