Applicant Intake Form

Applicant Intake Form

This form is for use by WDRI only. Please answer all questions honestly.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Education
Education History (list all schools attended, degrees obtained, and years attended. Write 'N/A' if not applicable.)
Employment History
Most Recent Job Title, Employer, dates of employment, and duties performed.
Second Most Recent Job Title, Employer, dates of employment, and duties performed.
Skills

Please list your relevant skills.
Please select the skills or experience you currently have. Select all that apply.

Other
Demographic Information

Please complete the following questions if you are comfortable doing so.
Gender
Race
Ethnicity
Veteran status
Disability status
Housing status

Other
Employment status at intake
Education level
Justice-involved or under supervision (probation, parole, home confinement, etc.)?
Recovery History

Please complete the following questions if you are comfortable doing so.
Recovery or substance-use history, if relevant. If not relevant, enter N/A.
History
I confirm that I will be able to pass a pre-employment drug screen.
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: