CATTARAUGUS COUNTY ONE STOP CAREER CENTER YOUTH PROGRAM 

S.S.# 

Name: 

Last 

First 

M.I. 

Date of Birth 

Age: 

Male / Female 

Address: 

City 

State 

Zip Code 

County 

Phone #: 

U.S. Citizen: YES / NO 

Ethnicity: White (not Hispanic) / Black or African American / Hispanic 
or Latino / Alaskan / American Indian / Asian (not Hispanic) / 
Hawaiian/Pacific Islander / Other 

Education: 

In School: Yes / No 

Highest grade completed 

Out of School: Yes / No 

Attending GED / Earned GED / High School Diploma / In College 

Year(s) of College Completed 

Vocational Degree / Course 

Weeks not Employed at Registration: 

Currently Employed: Yes / No 

Is Customer: ___ Disabled / ___ Disabled with imped. / ___ Not 
Disabled 

COMMENTS: 





Migrant / Seasonal worker: Yes / No 

Military Service: 

Males ~ Registered with Selective Service: Yes / No 

Contact Preferences: Use Postal / Primary Phone / Alt. Phone / E-Mail 
/ Fax 

Employment Objective: 

Acceptable Job Locations: 

Within 5 / 10 / 25 / 50 / 100 miles of ZIP Code ________ 

Driver License: Yes / No 

Class: 

State: 

Additional Skills: 





Is Customer: ___ Married / ___ Divorced / ___ Unmarried 

Is Customer: ___ Not a family member / ___ Other family member

___ Parent in 1-parent family 

___ Parent in 2-parent family 


Members of Household: (please list)

First Name / Last Name / Relationship to **Customer** / Age / 
Dependent ~ Yes / No










Is Customer a parenting youth? Yes / No 

If female, pregnant Yes / No    Delivery date: ___ / ___ / _____

Is Customer an Offender? Yes / No 

If yes, Probation Officer: 

If yes, Current Legal Issues: 





Household Income: 

Is anyone employed, self-employed, or receiving any income? (ex. 
Support / Social Security / UIB, etc.) 

Yes / No 

** ALL INCOME MUST BE NOTED **
Name / Relationship to Customer / Income Source-Employer's Name / 
Current Gross Income / Income in last 6 months 










Does any household member receive benefits under one or more of these 
programs? Yes / No

Benefit             Yes / No       Amount        Case #         Person 
who receives benefit
Family Assistance
HEAP
MA
FS
SSI 

Have you ever been involved in the Youth Program? Yes / No 

WORK HISTORY: List jobs held in the past 26 weeks (Begin with current 
or most recent employment) 

Employer: 

Address: 

Job Title: 

Job Duties: 

Hours/wk: 

Pay Per Hour: 

Start Date: ___ / ___ / _____ 

End Date: ___ / ___ / _____ 

Reason for leaving (if applicable): 



Employer: 

Address: 

Job Title: 

Job Duties: 

Hours/wk: 

Pay Per Hour: 

Start Date: ___ / ___ / _____ 

End Date: ___ / ___ / _____ 

Reason for leaving (if applicable): 



Comments: 








CERTIFICATION STATEMENT: 

I certify that the information contained in this document is true and 
correct. I understand that the information is subject to verification 
Under Part 665, Section 18 of the United States Code. Fraud is subject 
to criminal prosecution with penalties up to $10,000 in fines and/or 
up to two years 
imprisonment. 

I also certify that I have received and reviewed the Cattaraugus One 
Stop Career Center Grievance Procedure. 



Applicant Signature 

Date ___ / ___ / _____ 

Parent of Guardian (if applicant is under 18 years) 

Date ___ / ___ / _____ 



3 References Names, Addresses and Phone #'s: 

1. 

2. 

3.