Goodwill Leadership Academy

Date *

Name *

Date of Birth *

Address *

Address

City

State/Province

Zip/Postal

Phone Number *

Alternate Phone Number

Email Address *

Race *

Gender *

Male

Female

Primary Language *

English

Spanish

Other

Hispanic Origin *

Yes

No

History of Military Service *

Yes

No

Person/Agency Referred by *

Are you a family member of a person who is in, or was in, military service? *

Yes

No

Primary Disability (check all that apply) *

Primary Disadvantaging Conditions (check all that apply) *

What is your annual income ($)? *

Income Source *

Primary Emergency Contact *

Name

Relation to you *

List the relationship of your primary emergency contact.

Phone Number *

List the phone number of your primary emergency contact.

Address *

Address

City

State/Province

Zip/Postal

Country

List the address of your primary emergency contact.

Top three job choices *

11

22

33

Example: janitorial, cashier, receptionist

Number of hours a week *

Availability *

What days and hours are you available?

Where can you work? *

List cities (Example: Fort Worth, Arlington)

Transportation *

I have a car

I ride the bus

I have a ride

Criminal Record *

Yes

No

Is it a felony?

Valid ID? *

Yes

No

Valid Driver's License?

Yes

No

Social Security Card? *

Yes

No

Are you a US Citizen? *

Yes

No

If no, do you have authorized documentation to work in the US?

Yes

No

Number of children? *

Top three barriers to employment? *

11

22

33

What is preventing you from getting a job?

Current Education Level *

Some High School

GED

High School Diploma

Some College

Post-Secondary Credential (occupational licenses, personnel certifications, short-term training certificates)

2 Year/Associates Degree (normally requires at least two but less than four years)

4 Year/Bachelor’s Degree

Graduate Degree (program of study after completion of an undergraduate or bachelor’s degree)

Which program(s) are you interested in? *

Have you been affected or impacted by COVID-19? *

Yes

No

Electronic Signature *

Type your name here to officially submit your ASR.

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