Rural & Remote Job Placement Support Application
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please rate your proficiency with the following remote skills:
*
Poor
Below Average
Average
Above Average
Excellent
Organization
Critical Thinking
Digital Communication
Team Player
Written Communication
Productivity
Time Management
Workflow
Software Technology
Interactive Video Conferencing
Collaboration
Problem Solving
Accountability
Goal Setting
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Please rate your proficiency with the following software tools (if any):
*
None
Beginner
Average
Above Average
Excellent
Cloud-based collaboration (e.g., Google Docs, Google Sheets, Dropbox, iCloud)
Project / Task Management (e.g., Asana, Trello, Airtable, Doist, Evernote)
Video Conferencing (e.g., Skype, Zoom, Appear.in, GotoMeeting, Google Hangouts/Meet)
Customer Relationship Management (CRM) (e.g., Hubspot, Salesforce, Zoho, Pipedrive, Oracle)
Accounting and Invoicing (e.g., Quickbooks, Freshbooks, Harvest, Invoice Ninja)
Freelancer Platforms (e.g., Upwork, Toptal, Freelancer, Hubstaff Talent, Fiverr)
E-Commerce Platforms (e.g., Ebay, Etsy, Bonanza)
Education (e.g., Canvas, Litmos, Blackboard, Udemy, Skillshare)
Design (e.g., Adobe Creative, Canva, Indesign)
Website Management (e.g., Wordpress, Squarespace, Wix, HTML)
Web Development (e.g., Java, Python, C#, Pluralsight)
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Please rate your ability in the following areas:
*
Poor
Average
Good
Excellent
Independent
Responsive
Articulate
Curious
Confident
Empathetic
Innovative
Flexible
Disciplined
Hardworking
Self-motivated
Dependable
Trustworthy
Proactive
Motivated
Tech Savvy
Focused
Do you know how to send emails with an attachment?
*
Yes
No
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Does your household income include streams of income from the following? (Select all that apply)
*
Online freelance work
Remote employment
E-commerce
None of the above
How much income have you earned as a remote worker?
*
None $0
Less than $25,000
$25,000 to $34,999
$35,000 to $49,000
$50,000 to $74,999
$75,000 to $99,999
$100,000+
How important to you is acquiring remote work skills?
*
1
2
3
4
5
Not at all Important
Very Important
1 is Not at all Important, 5 is Very Important
What prompted your interest in remote work?
*
What are your long term career goals?
*
What is on your must-have list for your dream job?
*
Do you believe that adequate wages are available in your local region?
*
Yes
No
Do you believe job opportunities are available in your local county that match your long-term goals?
*
Yes
No
If not, do you plan to permanently leave your current region in the next 3 years?
*
Yes
No
Do you have consistent and reliable access too internet at home?
*
Yes
No
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What type / speed of internet do you have at home?
*
DSL
Cable
Fiber
Satellite
Cell Phone / Tethering
Other
What is your home internet connection speed? (To measure your speed visit www.speedtest.net)
Download Speed (Mbps)
*
Upload Speed (Mbps)
*
How would you rate your level of job satisfaction?
*
1
2
3
4
5
Very Dissatisfied
Very Satisfied
1 is Very Dissatisfied, 5 is Very Satisfied
How would you rate your current work-life balance?
*
1
2
3
4
5
Poor Work Life Balance
Ideal Work Life Balance
1 is Poor Work Life Balance, 5 is Ideal Work Life Balance
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On average, what is your commute time (one way)?
*
1 - 5 minutes
5 - 15 minutes
15 - 30 minutes
30 - 45 minutes
45 minutes - 1 hour
1 hour - 1.5 hours
1.5 - 2 hours
2 - 3 hours
3+ hours
Do you commute outside your county to get to work?
*
Yes
No
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Please select your age range.
*
In high school
18 - 25
26 - 30
31 - 35
36 - 40
41 - 45
46 - 50
50+
Please select your gender.
*
Male
Female
What is your marital status?
*
Single (never married)
Married or domestic partnership
Widowed
Divorced
Separated
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Veteran Status
*
Veteran
Disabled Veteran
Not a Veteran or undisclosed
Spouse of Veteran
No Response
What is the highest degree or level of education you have completed? If currently enrolled in school, please indicate the highest degree received.
*
In high school
Some high school, no diploma
High school graduate, diploma or the equivalent (for example: GED)
Some college credit, no degree
Trade/technical/vocational training
Associate degree
Bachelor's degree
Master's degree
Professional degree
Name of school / University / College / Institution last attended
*
Degree, Certifications, training, or recognitions earned:
*
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Select all that apply for your current employment status.
*
Employed full-time
Employed part-time
Unemployed and currently looking for work
Unemployed and not currently looking for work
Underemployed
Student
Retired
Homemaker
Self-employed
Unable to work
Please list out what type of remote job you are interested in (I.E. Finance, Education, Sales, Marketing, Healthcare, HR/Payroll, etc..)
*
What is your current personal income level?
*
$0 (Unemployed)
Less than $25,000
$25,000 to $34,999
$35,000 to $49,000
$50,000 to $74,999
$75,000 to $99,999
$100,000+
What is your current household income level?
*
$0 (Unemployed)
Less than $25,000
$25,000 to $34,999
$35,000 to $49,000
$50,000 to $74,999
$75,000 to $99,999
$100,000+
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What level of income are you looking (and are qualified) for?
*
Less than $25,000
$25,000 to $34,999
$35,000 to $49,000
$50,000 to $74,999
$75,000 to $99,999
$100,000+
Submit
Please upload your resume:
*
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