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2. Employment and Training Services Form
   Please complete this form and a staff member will be in contact with you. If you would like more information, please call any Orange County DSS location at (919) 245-2800 or NC Works/ Skills Development Center at (919) 245-4335.
4. JOB SEEKER INFORMATION
6. Name
7. Date of Birth
   Date of Birth
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Email Address
20. REFERRAL SOURCE
22. Referral Date
    Referral Date
23. Person/ Organization/ Program
25. Email Address
26. Phone Number
30. Veteran?

    1. Yes
    2. No
31. Do you receive Public Assistance? If so, please indicate which:

    1. Food and Nutrition Services
    2. Medicaid
    3. TANF

    Check all that apply
32. Services of Interest

    1. Basic Adult Education (GED)
    2. On-the-Job Training
    3. Job Search/ Resume Assistance
    4. Post-Secondary Education
    5. Paid/ Unpaid Work Experience
    6. Labor Market Information
    7. Continuing Education/ Credentials
    8. Job Readiness Training
    9. Career Exploration

    Check all that apply
34. Challenges to Employment/ Training

    1. Lack of Skills
    2. Child Care
    3. No GED/ High School Diploma
    4. Housing/ Homeless
    5. Criminal Record
    6. English Language Learner
    7. Limited Work History
    8. Disability
    9. Transportation

    Check all that apply
35. Employment and Training Goals
Leave This Blank:


37. Submit Submit and Print

* indicates a required field