T2W
DEI
Initial Application
Date: ________________
General
Customer Name: _____________________________ Birth Date: _________ SS#: _________________________
Address: _____________________________________________________________ Zip Code: ______________
Phone Number: _________________________ Email: _______________________________________________
Do you receive Social Disability benefits?
SSI or SSDI
Are you a Veteran? ________________
Is it difficult for you to cover your monthly expenses? ____________ Do have a bank account? _______________
What are your financial goals? 1)______________________2)_____________________3)___________________
Work Information
Do you have a Resume? Yes_____ No _____
Do you need assistance with your resume? Yes _____ No _____
Are you registered in Employ Florida ? Yes _____ No_____ Is your resume active in EFM? Yes _____ No _____
Rate your computer skills (1 – 10 highest):________ Have you worked in the last 18 months? Yes ____ No ____
Are you currently receiving Unemployment Compensation? Yes _____ No _____ Number of months: __________
Are you currently receiving Food Stamp assistance? Yes ______ No ______ Enrolled in SNAP E&T___________
Other Service/Assistance Providers used: _______________________________________________________
Check all that apply below:
Barriers to Employment
No High School Diploma/GED
Limited Work History/Experience
No or Limited Transportation
Clean driver’s license - Yes / No
Limited Job Retention
Lack of work Clothing
Legal Issues/Ex-Offender
Health/Mental Health Disability
Physical Disability
Substance Use
Domestic Violence Issues
Background Issues
Housing/Homeless
No Childcare
Other (such as Sensory or Learning Disability) -
Strengths
Post Secondary Education
Recent Work Experience
Communication Skills
Adaptive
Analytical/ Formulating
Evaluate/ Examine /Explain
Creative Thinking /Implementation
Managing/ Monitoring/ Mentoring
Planning /Presenting
Problem Solving
Teaching/ Trouble Shooting
Tracking /Details
Writing
Coordinating / Compiling/ Checking
Education Goal:
Highest Level of Education: ____ High School ____ Certificate ____ Associate ____Bachelor’s ____ Master’s
List Certifications/Degrees: ___________________________________________________________________
Currently enrolled or planning on enrolling in school? Yes _____ No _____
What Program: __________________________ Training Provider: __________________________
Anticipated Start Date: _____/_____/_____
Anticipated End Date: _____/_____/_____
1
PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number
is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one
individual from another, and for tracking and reporting purposes.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone
numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.
1/23/2015
Employment Goal:
What was your last job? _____________________________________Last employment date _______________
Currently employed?
Yes
No
Hours/Week:
Wage:
Short Term Goal (3-12 mo.) Job Title: _____________________________ Hours/Week: _______ Wage: _______
Long Term Goal (3-5 yrs.)
Job Title: _____________________________ Hours/Week: _______ Wage: _______
SKILLS: (Please check off the skills/knowledge you currently possess)
OFFICE
____Typing WPM
____Reception
____Word
____Outlook
____Customer Service
____Bookkeeping
____Data Entry
____Excel
____PowerPoint
RETAIL/FOOD SERVICE/HOSPITALITY
____Cashier
____Food Prep.
____Server
____Housekeeping
____Sales
COMPUTER
____Networking
____ Help Desk
____Internet
____Programming
OTHER PROFESSIONAL SKILLS
____Security
____Management
____Education
Action Plan:
Employment Objectives:
Planned Completion
To obtain training in a demand occupation to become self sufficient.
To obtain a Part time Job as a _____________________________
To obtain a Full time job as a ______________________________
To attend Job Center Resume Workshop to assist in Job Search:
I have attended or assigned to attend the Disability Orientation including basic work incentives information,
phone numbers, the SSA Red Book and have been encouraged to use this information to get answers to specific
questions about going back to work and how it will affect my benefits.
*Remember you MUST report wages directly to Social Security!
Customer Signature: _________________________________________
Referred to:
Date: ________________
Smart Money____ SNAP/FS ____ VR ____ VITA/My Free Taxes ____ WIA ____ IDA ____
Other: ______________________________________________________________________
Notes:
2
PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number
is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one
individual from another, and for tracking and reporting purposes.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone
numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.
1/23/2015
For your Ticket to Work appointment for please complete and bring the following.
Employ Florida Marketplace www.employflorida.com - Register or update your current information and
complete the Resume section and the Virtual Recruiter.
Driver License
Social Security Card
Current resume - If you do not have one, please sign up for a resume workshop.
Interest Inventory
Complete Florida E-choices Assessment:
1. Go online to https://secure.flchoices.org/
2. Click on the adult version of the “Career Planning”
3. Select the assessment, “Interest Profiler” and complete, you may complete additional assessments listed
(Career Cluster, Basic Skills Survey, Transferable Skills or Work Values Sorter)
4. Print the results page and bring to you appointment or you may e-mail the results.
O-net Job Descriptions
Locate 3 occupations/job titles that you are interested in pursuing
1. Go to www.onet.org
2. Click on find occupations
3. Locate 3 job titles that you are interested in pursuing and print
Bring copies of your assessment results and the job descriptions to you next meeting.
_____________________________________________________________________________________________
Resources:
Skills profiler: www.careerinfonet.org
Research new careers: www.myskillsmyfuture.com
Career exploration and information on numerous occupations: www.careeronestop.org
Computer, reading or math skills training (free): GCF Learning Free www.gcflearnfree.org
Social Security Administration and disability benefits: http://www.ssa.gov/work/
Ticket to Work Information: http://www.socialsecurity.gov/work/receivingbenefits.html
CareerSource Pinellas: www.careersourcepinellas.com
SNAP-Job search and transportation assistance: South County (727) 608-2500 or North County (727) 608-2428
Safelink - a service provider of free cell phones with 250 minutes.
Bank On – Financial stabilisation programs
TAX assistance : VITA, MyFreeTaxes, EITC
Financial Education – Money Smart program is located on the Resource Area computers.
Financial Workshop in the Tarpon office.
To find affordable housing: www.FloridaHousingSearch.org or www.GoSection8.com
Job search engines for persons with disabilities
Disabled Person: https://www.disabledperson.com/
Getting Hired: http://www.gettinghired.com/
Hire Disability Solutions: http://www.hireds.com/
One More Way: http://www.onemoreway.org/
Employer Assistance and Resource Network: http://askearn.org/
Ability Jobs: http://www.jobaccess.org/
Think Beyond the Label: http://thinkbeyondthelabel.com/
http://abilityJobs.com
http://jobs.disabilityscoop.com
https://abilitieswork.employflorida.com
To schedule an appointment to meet with a Disability Specialist:
scaum@careersoucepinellas.com, (727) 608-2552
3
PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number
is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one
individual from another, and for tracking and reporting purposes.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone
numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.
1/23/2015