Job Connection Center
JCC Location
*
Defiance
Madison
Name
*
First Name
Last Name
Email
*
example@example.com
County
*
Defiance
Fulton
Hancock
Henry
Lucas
Ottawa
Paulding
Putnam
Sandusky
Seneca
Williams
Wood
Choose From List
ZIP Code
Date
-
Month
-
Day
Year
Today's Date
Gender
Female
Male
Non-Binary
Age
24 or under
45-54
25-34
55-64
35-44
65 or over
Race
African American
American Indian
Asian
Caucasian
Hawaiian/Pacific Islander
Hispanic/Latino
Two or More Races
Other
Education
Attending High School
Less Than High School
High School Diploma/GED
Some College
Trade School
Associates Degree
Bachelor's Degree
Graduate Degree
Post Graduate Degree
Living Arrangements
Independent (rent or own)
Family/Friends
Shelter
Group Home
One The Street
Other
Transportation
Own
Family/Friends
Provider
Public
Other
Career Interests
United States Veteran?
Yes
No
War Veteran?
Yes
No
Specify War
Is someone in your family a US Veteran or currently active in the military?
Yes
No
Please Explain
Do you have any of the following barriers to employment?
Advanced Age
At-Risk Youth
Chronically Poor/Economically Challenged
Chronic Unemployment
Currently Unemployed
Displaced Worker
Homeless
Illiterate
Lack of Social Support
Offender/Ex-Offender
School Dropout
Single/Teen Parent
Transportation Issues
Welfare Recipient
None
Other
Disabilities
Alcohol and/or Drug Recovery
Arthritis/Other Rheum. Dx.
Autism
Cardiac/Pulmonary D/O
Cerebral Palsy/Spina Bifida
Developmentally Disabled
Fibromyalgia
Hearing Impairments
Learning Disability
Mental Health
Multiple Scierosis
Muscular Dystrophy
Orthopedic
Seizure Disorder
Visual Impairments
Traumatic Brain Injury
Visual Impairments
None
Employment History
Please write about your current or most recent employment
Employer
Employer Phone Number
-
Area Code
Phone Number
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor
Job Duties?
Reason for Leaving?
Submit
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