Individualized Career Services Packet Instructions:
THIS FILE MUST BE DOWNLOADED TO YOUR COMPUTER
IN ORDER TO BE FILLED OUT PROPERLY PLEASE SEE DOWNLOAD INSTRUCTIONS ON OUR WEBSITE
The Individualized Career Services Packet is intended to help staff determine an individual’s suitability and eligibility for services. Please print and complete the packet as thoroughly as possible.
Once Packet is complete you can:
1. Scan the entire packet to: [email protected]
2. Save the completed electronic fillable PDF and submit to: [email protected]
3. Mail the entire Packet to: 56 S. Lincoln Street Stockton CA 95203
4. Drop off the Packet at the Stockton WorkNet Center, 56 S. Lincoln Street Stockton Ca 95204 If you are unable to print or electronically fill out the packet, please call 209-468-3500 and a staff member will be able to assist you with completing the packet.
Welcome to WorkNetA Proud Partner of
America’s Job Center of California
IntensiveServiceProcess IntensiveServiceApplicationPacket√ Checkoffasyoucomplete:
• Orientation• Registeratwww.caljobs.ca.gov• IntensiveServiceApplicationReview• Certification/CASASTesting• ComprehensiveAssessment
(CareerScope&WorkKeys)• IndividualEmployabilityPlan
(withCaseManager)• CareerTrackorJobTrack• Employment
( )CompleteCalJobsRegistration
( )CompleteBackgroundWizardonCalJobs(printandattach)
( )AttachUpdatedCalJobsResume
( )CompletePre-eligibilityWorksheetforWIOA
( )CompleteandattachQuestionnaire
( )CompleteGenericApplicationlegibly
( )SelectiveServiceVerification(www.sss.gov)(ThisonlyapplyforMalesbornafter1960)
Upon completion of packet, return it to any WorkNet center. You will be contacted by phone and/or e-mail for the next step in your process. Please be advised that completing all of these steps does notguarantee you will be selected for training or additional services.
Customer Name: _____________________________Best contact # to reach you: ____________________
Last 4 of SS#_____________
**************************************************************************************************
FORSTAFFUSEONLY:
Receivedby:(StaffName)______________________________________(Date):_____________________
******************************************************************************************PacketAssignedto:(StaffName)________________________ Date:_______________________
ReviewedbyCaseManagerforpacketcompleteness:___________________________________________Complete,forwardedbacktoClericalStaff: ()JobTrack()CareerTrack ()NotYetInitial/Date:____________________
()ReferredOutReason:_______________________________________________________________________________________________________________________________________________________________________
******************************************************************************************PacketAssignedforCertification:_________________________ Date:________________________IfCertificationisnotScheduled,forwardedbacktoClerical:()NoShow()NoCall()Ineligible
Revised04/01/2020bpc
Pre-EligibilityWorksheetforWIOA
Name:___________________________________________________________________Date:___________________
AreyoucurrentlyreceivingCashAid,FoodStampsorGeneralAssistance? ( )Yes ()No
Areyoubetweentheagesof18-21? ( )Yes ( )No
Ifyes,haveyouobtainedyourhighschooldiplomaorGED? ( )Yes ( )No
AreyouacitizenoftheUnitedStates? ( )Yes ( )No
DoyouhavetherighttoworkintheUnitedStates? ( )Yes ( )No
AreyouamalebornonorafterJanuary1,1960? ( )Yes ( )No
Ifyes,areyouregisteredwithSelectiveService? ( )Yes ( )No
üIfyes,pleaseattachRegistrationprintoutfromwww.sss.gov,verifyingthatyouareregistered.
Wereyoulaidofforterminatedfromyourlastjob? ( )Yes ( )No
Ifyes,pleaseattachemployerletterorunemploymentverification.Areyoureceivingunemploymentinsurancebenefits? ( )Yes ( )No
Pleaseprovidethenumberinyourfamilycurrentlyresidinginthehouseholdincludingyourself._________Pleaseincludeonlyself,spouseandminorchildren(17&under)residinginhomerelatedtoyoubyblood,marriageoradoption.
FamilyIncome:Pleasecheckallthatapplyandentertheamountofincomereceivedforthepast6months.
Pleasebepreparedtoprovideverificationofeachsourceofincomeyouhavereceivedinthepast6months.Forwages,acceptabledocumentsincludeW-2,paystubwithYTDamountlisted.
Month YourWages
SpouseWages
SSARetirement
RegularPension/Retirement
SSASurvivors
ChildSupport
UIB CashAidAssistance
OtherCountableIncome
OtherNon-CountableIncome
123456Total
STAFFUSEONLY:AppearsEligible:()ADULT()DISLOCATEDWORKER()INELIGIBLE/REFERREDOUT
Revised04/01/2020BPC
QUESTIONNAIRE
Name:___________________________________________________________Date:__________________________
SERVICESDESIRED
( )IdentifyingCareerInterests&Goals
( )Skills&AbilitiesAssessment
( )CareerCounseling
( )LaborMarketInformation
( )HelpwithInterviewing
( )HelpwithResumeWriting
( )OntheJobTraining
( )JobSearchResources
( )VocationalTrainingOptions
( )UnemploymentInsuranceAssistance
( )FinancialPlanning
SocialServicesInformation:()Foodstamps()PublicAssistance()Medi–CalorHealthInsurance
( )VeteransServices ()FarmWorkerServices
Other:____________________________________________________________________________________________
EDUCATION
HighSchoolDiploma/GED:()Yes()NoIfno,reasonfordroppingout:___________________________
Areyoucurrentlyattendingschool()Yes()NoIfyes,nameofschool:___________________________
Lastgradecompletedanddatelastattendedschool:__________grade__________date
Post-SecondaryEducation:()Yes()No Major:_________________________________________
PleaselistVocationalTrainingCertificatesyouhavereceivedevenifexpired:__________________________________________________________________________________________
Whatlanguagesdoyouspeakfluently?()English()Others_____________________________________
AreyouaVeteran?()Yes()No MilitaryTraining?()Yes()No
ListTrainingreceivedinMilitary:__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Questionnairepage1of4revised03/29/19-bpc)
JOBREADINESS
EmploymentBackground:(checkifapplicable)
_______ Currentlyemployedandnotmakingself-sufficientwagetomakeendsmeet.
_______ Currentlyemployedandnothappywithcurrentemployment.
_______ Currentlyunemployed.
Ifunemployed,howlonghaveyoubeenunemployed?________________________________
Reasonforpresentunemployment?_______________________________________________
AreyouACTIVELYseekingemployment?()Yes()No
Ifyes,pleaseanswerthefollowing:
Haveyoueverhadyourresumecritiquedbysomeoneprofessional?_____________________
Howoften,doyousearchforwork?_______________________________________________
Whatkindofsearchdoyoudo?()newspaperads()onlinesites()doortodoor
()randomfromthephonebook()Other:_____________________________________
Whatkindofjobareyouseeking?________________________________________________
Whatskillsdoyouhaverelatedtotheworkyouareseeking?
___________________________
_____________________________________________________________________________
Whatexperiencedoyouhaverelatedtotheworkyouareseeking?
______________________
_____________________________________________________________________________
Otherskillsorexperienceyouhaveasidefromthosealreadylisted?_____________________
_____________________________________________________________________________
Indicatelowestwageyouwillaccept:______________________________________________
Questionnaire,Page2
Inyourobservationofyourself,please√thosethatbestdescribesyou:
√ Iam: √ Iam:
TeamPlayer,Iliketoworkwithateam Independentworker,Iliketoworkalone
Punctual,IamneverlateIamlateoftenduetolackoftransportationorotherissues.
Dependable,IrarelymissadayofworkImissworkoftenduetolackoftransportationorotherissues.
Socialperson,Iliketobearoundothersandliketohavecommunicationandinteractionduringmydayonthejob.
Iliketocomein,getmyworkdoneandgohomewiththemostminimalsocialinteractionaspossible
ItryhardtoreachmyhighestpotentialandIamalwayslookingforapromotionalopportunity.
Iamsatisfiedwithbeingfrontlinestaffanddon’treallytrytomoveup.
Inyourobservationofthecircumstancesyouarecurrentlyexperiencing,whichdoyoufeelmakeitdifficultforyoutofindorkeepajoborcompletetraining.Check√thosethatapply:
Iliveinanisolatedarea Myskillsarerusty. Ihavefinancialdifficulties
Iexperienceagediscrimination
TherearenojobsinmyfieldIlackadequatefood
Ilackconfidence Ihavenotelephone Ilackproperclothingforwork
IhavealowcreditscoreIlackrequiredtoolsforthejobIamqualifiedfor
Ihavebeenlongtermunemployed.
IcannotdecidewhattypeofworkIwant
Ineedchildcareassistance Ihavenotransportation
Ilackvocationaltrainingand/oreducation
Ihavegapsinmyemploymenthistory
Ilackmotivation
IamlimitedEnglishspeaking IlackfamilysupportIamunabletopassacriminalbackgroundcheck
Ihavenoworkexperience Ihavenoworkexperience Iamhomeless
Isthereanyotherinformationorsituationthatyoufeelmayimpactyourabilitytoobtainemploymentorattendtraining?Ifyes,pleaseexplain:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Questionnaire,Page3
TRANSPORTATION
Doyouhavereliabletransportation?()Yes()No
Type:()Ihavemyowncar()Irelyontheuseofsomeoneelse’svehicle.
IfyouareseekingemploymentasaDriver,pleaseanswerthefollowing:
DoyouhaveacurrentvalidCAdriver’slicense?()Yes()NoClass:()C()B()AIfNo,explainwhy:_____________________________________________________________
HaveyoueverheldanyotherclasslicensebesidesaC(generallicense)inthepast?()Yes()No
Ifso,whatclassandwhydoyounolongerpossessthatlicense:
______________________________________
_________________________________________________________________________________________
Howfarareyouwillingorabletotraveltoacceptemployment?
()WithinSanJoaquinCounty(Stockton,Manteca,Lodi,Tracy)
()OnlyinthelocalcityIliveinwhichis_________________________________________
()OutsideofSanJoaquinCountyupto____________miles.
CHILDCARE
School Status—Please Check One ()Infanttopreschool( )elementaryschool( )middleschool( )highschool()outofschool()Infanttopreschool()elementaryschool( )middleschool( )highschool()outofschool()Infanttopreschool( )elementaryschool( )middleschool( )highschool()outofschool()Infanttopreschool( )elementaryschool( )middleschool( )highschool()outofschool()Infanttopreschool( )elementaryschool( )middleschool( )highschool()outofschool()Infanttopreschool( )elementaryschool()middleschool()highschool()outofschool()Infanttopreschool( )elementaryschool( )middleschool( )highschool()outofschool
Describeyourchildcarearrangement:
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
Thankyouforcompletingthisquestionnaire. Questionnaire,Page4
AgeNumber of Dependent Children:_______ Please Provide the following information for each child
NAME (LAST, M.I., FIRST)
PRE-EMPLOYMENT QUESTIONNAIREEQUAL OPPORTUNITY EMPLOYER
POSITION
SCHOOL
SUBJECTS OF SPECIAL STUDY/VOLUNTEER OR RESEARCH WORK/WORKSHOPS OR SPECIAL TRAINING/SKILLS
U.S MILITARY OR NAVAL SERVICE
NAME ADDRESS PHONE NUMBER BUSINESS YEARSKNOWN
RANK
HIGH SCHOOL
BUSINESS/TRADE/TECHNICAL
COLLEGE
GRADUATE
NAME AND LOCATION
NAME
CITY/STATE
COURSE OF STUDY DEGREE or DIPLOMA
ARE YOU EMPLOYED NOW? IF SO, MAY WE CONTACTYOUR PRESENT EMPLOYER
EVER APPLIED TO THISCOMPANY BEFORE?
YES NO
YES NO
WHERE? WHEN?
YES NO
DATE YOU CAN START SALARY DESIRED
PERSONAL INFORMATION
EMPLOYMENT DESIRED
EDUCATION
GENERAL INFORMATION
REFERENCES GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR
DATE
CURRENT ADDRESS CITY
CITY
STATE
SOCIAL SECURITY NUMBER
STATE
ZIP CODE
ZIP CODEPERMANENT ADDRESS (If different from current address)
PHONE NUMBER E-MAIL ADDRESS
NAME
CITY/STATE
NAME
CITY/STATE
NAME
CITY/STATE
APPLICATION FOR EMPLOYMENT
Please complete fully and accurately, listing your current or most recent employers first,continuing backward in time. if additional space is needed, please attach another page.
“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that,if employed, falsified statement on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed to give you any and all informationconcerning my previous employment and any pertinent information they may have, personal or otherwise and releaseall parties from all liability for any damage that may result from furnishing same to you.
I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of paymentof my wages and salary, be terminated at any time without any prior notice.”
AUTHORIZATION
EMPLOYMENT HISTORY
Employer’s Name
SIGNATURE DATE
Employer’s Telephone Number
Employer’s Address
City, State, ZIP
Supervisor’s Name
Reason for Leaving
Starting Hourly Wage Ending Hourly Wage
Employed From Job Duties:
Your Title
Duties cont.
To
Employer’s Name Employer’s Telephone Number
Employer’s Address
City, State, ZIP
Supervisor’s Name
Reason for Leaving
Starting Hourly Wage Ending Hourly Wage
Employed From Job Duties:
Your Title
Duties cont.
To
Employer’s Name Employer’s Telephone Number
Employer’s Address
City, State, ZIP
Supervisor’s Name
Reason for Leaving
Starting Hourly Wage Ending Hourly Wage
Employed From Job Duties:
Your Title
Duties cont.
To
Employer’s Name Employer’s Telephone Number
Employer’s Address
City, State, ZIP
Supervisor’s Name
Reason for Leaving
Starting Hourly Wage Ending Hourly Wage
Employed From Job Duties:
Your Title
Duties cont.
To
Employer’s Name Employer’s Telephone Number
Employer’s Address
City, State, ZIP
Supervisor’s Name
Reason for Leaving
Starting Hourly Wage Ending Hourly Wage
Employed From Job Duties:
Your Title
Duties cont.
To