New York State Department of Labor Customer Registration Form ES 100 (4-03) Equal Opportunity Employer/Program Auxillary aids and services are available to individuals with disabilities. DATE: Required items are indicated with asterisk * and bold type - Please print clearly Customer Data____________________ * 1. Social Security # * 2. Last Name * 3. First Name 4. M.I. 5. Date of Birth 6. Gender: Male / Female * 7. Street Address Apt. # * 8. City. .*9. State, *10. Zip Code (+4 not required) 11. County 12. Country, if not US 13. Phone Ext. 14. Alternate Phone Ext. 15. Fax Ext. 16. E-Mail Address *17. Are you a US Citizen? Yes / No If not, are you authorized to work in the United States? Yes / No Ethnicity/Race____________________ 18. Ethnicity: Hispanic or Latino / Not Hispanic or Latino Note: This question is voluntary. Information will be kept confidential and is intended for use solely in connection with record keeping and affirmative action requirements. You will not be penalized for refusal to answer. 19. Race: (Check all that apply) White / Black or African American / American Indian or Alaska Native / Asian / Native Hawaiian or Other Pacific Islander Note: This question is voluntary. Information will be kept confidential and is intended for use solely in connection with record keeping and affirmative action requirements. You will not be penalized for refusal to answer. Education & Employment____________________ *20. Education (Circle or check highest level completed) Grade: None / 1 2 3 4 5 6 7 8 9 10 11 12 / No Diploma / HS Graduate / GED College: 1 yr. 2 yrs. 3 yrs. 4 yrs. plus If college, check all that apply Some College / Vocational Degree/Certificate / Associate's Degree / Bachelor's Degree / Master's Degree / Doctoral Degree *21. Are you attending a secondary, vocational, technical or academic school full-time? Yes / No If you are between terms, do you intend to return to school? Yes / No *22. How many weeks were you out of work in the last 26 weeks? *23. Are you currently employed? Yes / No 24. Do you want your resume to be listed on America's Job Bank(AJB) on the Internet for employers to see? Yes / No 25. If you answered yes to question 24, do you want your address and telephone information to be listed on AJB? Yes / No If you answered no, you must provide an e-mail address (see question 16) in order for a potential employer to contact you. Programs/Public Assistance____________________ 26. Are you or any member of your family receiving any Public Assistance (such as food stamps, cash benefits, SSI, etc.)? Yes / No If you answered yes to question 26, please indicate what Public Assistance you are receiving 27. Are you a person with a disability? Yes / No Note: This question is voluntary. Information will be kept confidential and is intended for use solely in connection with record keeping and affirmative action requirements, and to determine program eligibility. You will not be penalized for refusal to answer. *28. Are you a Migrant/Seasonal Worker? Yes / No If Yes, check one of the following: ___ Migrant Farm Worker ___ Migrant Food Processor ___ Seasonal Farm Worker ___ Military Service *29. Are you a veteran? Yes / No If yes, provide dates of Active Service __ / __ / ____ through __ / __ / ____ 30. Are you an Other Eligible spouse of a veteran? Yes / No Other Eliaible: The spouse of a person who: a) was killed in action or who died of a service connected disability; b) is serving on active duty who is listed as 1. missing in action, 2. captured in the line of duty, or 3. forcibly interned in the line of duty for a total of 90 days or more; or c) has a permanent total service connected disability. If you answered "No" to both 29 and 30, go to question 32. *31. Are you receiving compensation for a service-connected disability? Yes / No If Yes, list % of disability _____ Note: This question is voluntary. Information will be kept confidential and is intended for use solely in connection with record keeping and affirmative action requirements and to determine program eligibility. You will not be penalized for refusal to answer. Employment and Shift Preference____________________ 32. Which kind of jobs are acceptable? Work Week: Full-time (30 hrs. per week or more) Part-time (Less than 30 hrs. per week) Any Duration: (length of employment) Reaular (Over 150 days) Temporary (3 days or less) Regular or Temporary (4-150 days) 33. Minimum salary required $ per - Hour / Day / Week / Month / Year / Other 34. Date you are available for work 35. Which shift(s) are you willing to work? (Check all that apply) First Second Third Split Rotating Any *36. How do you prefer to be contacted? (Check all that apply) Mail / Primary Phone / Alternate Phone / Fax / E-Mail Employment Objective____________________ *37. Employment Objective/Kind of work wanted Job Title *38. List most recent occupation(s)/job(s) Job Title Experience in this Job Years Months Years Months Years Months Acceptable Job Locations____________________ *39. I am willing to work within the following zip codes or states or countries: Choose either A, B, or C. You may enter up to 3 zip codes or states or countries. If A is chosen, circle number of miles and enter zip code. A. Zip Code B. States C. Countries 5 10 25 50 100 miles of zip code ________ 5 10 25 50 100 miles of zip code ________ 5 10 25 50 100 miles of zip code ________ Note: (Applies to A only) If you are receiving Unemployment Insurance, you may be required to travel 1 hour by private transportation, or 1 1/2 hours by public transportation. 40. Work History If you have job experience, please put as much detail in this section as possible to improve our chances of helping you find work. Complete all required items for each employer. Enter the most recent employment first. * Job Title * Employer * Address * City * State * Country, if not US Start Date (mo./yr.) ___ / _____ End Date (mo./yr.) ___ / _____ Supervisor Phone No. * Wage $ per hr / day / wk / mo / yr / other * Reason for Leaving * Job Duties: * Job Title * Employer * Address * City * State * Country, if not US Start Date (mo./yr.) ___ / _____ End Date (mo./yr.) ___ / _____ Supervisor Phone No. * Wage $ per hr / day / wk / mo / yr / other * Reason for Leaving * Job Duties: * Job Title * Employer * Address * City * State * Country, if not US - Start Date (mo./yr.) ___ / _____ End Date (mo./yr.) ___ / _____ Supervisor Phone No. * Wage $ per hr / day / wk / mo / yr / other * Reason for Leaving *Job Duties: Drivers License____________________ 41. Do you have a driver's license? Yes / No If you answered "No", go directly to question 44. What type of license do you have? __ Class A (Tractor Trailer) __ Class B (Truck/Bus) __ Class C (Light Truck Com'I.) __ Class Cn (C-non-CDL) __ Class 0 (Operators) __ Class E (Taxi) __ Class M (Motorcycle) Issuing State Endorsements: __ Passenger Transport __ Hazardous Materials __ Tank Vehicles __ Motorcycle __ School Bus __ Doubles/Triples __ Tank Hazard __ Air Brakes 42. Do you need public transportation to get to a job? Yes / No 43. Do you own or have access to a vehicle? Yes / No Certificates/Licenses____________________ 44. Do you have an occupational certificate or license? Yes / No If you answered "No", go directly to question 45. * Certificate/License * Issuing Organization or Locality Issue Date: (mo./yr.) State * Country Additional Certificate or License: * Certificate/License * Issuing Organization or Locality Issue Date: (mo./yr.) ___ / _____ State * Country Schools____________________ 45. Do you have a degree, diploma or educational certificate? Yes / No If you answered "No", go directly to item 46. * Course of Study * Degree Date Completed (mo./yr.) ___ / _____ * Issuing Institution * State * Country Additional degree, diploma or educational certificate: * Course of Study Degree Date Completed (mo./yr.) ___ / _____ * Issuing Institution * State * Country *46. Job Skills: List at least one Include skills and abilities that you used in your job(s) or that you have acquired through school/training. For example, automobile mechanic, carpentry, welding, typing, computer hardware/software, etc. Please use the suggested skills inventory available in the One-Stop Resource Room as much as possible. Also, include any foreign languages in which you are fluent. 47. List any honors you have received or outside activities you participate in: