New York State Department of Labor
Customer Registration Form
DATE:
Customer Data
1.
Social Security #
2.
Last Name
3. First Name
5.
Date of Birth:
6. Gender:
7.
Street Address:
8.
City
9. State
Male
Female
10. ZIP Code
11. County
12. Country, if not US
13. Phone:
14. Alternate Phone:
15. Fax:
4. M.I.
16. E-Mail Address:
17. Are you a U.S 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
Asian
Black or African American
American Indian or Alaska Native
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: Please indicate highest level completed
Highest Grade Completed (1-12)
College:
1 yr.
2 yrs.
No Diploma
3 yrs.
4 yrs. plus
HS Graduate
GED
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?
If you are between terms, do you intend to return to school?
Yes
Yes
No
No
22. How many weeks were you out of work in the last 26 weeks?
23. Are you currently employed?
Yes
No
24. Your resume including name, address, telephone, and e-mail (if available) will be posted on the Internet for employers to view on the
(NYJB) New York Job Bank (www.ajb.org/ny/), which is part of America’s Job Bank, unless otherwise instructed. Posting your resume
will give it greater exposure to employers and job opportunities both in NYS and nationally. If you do not wish to have your resume fully
disclosed on the Internet, check one of the boxes below.
Post my resume as “Confidential”. Your resume will exclude your name, address, and telephone.
ES 100 (1-07)
Equal Opportunity Emplover/Program
___________________ Auxiliary aids and services are available upon request to individuals with disabilities. _____
24. Check here to indicate that you have been made aware of the provisions of the “Equal Opportunity is the Law” notice. (See last page of this
emailed form)
Proarams/Public Assistance
25. 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
26. 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:
30. Are you an Other Eligible spouse of a veteran?
Yes
/
/
through
/
/
No
Other Eligible: 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)
33. Minimum salary required $
34. Date you are available for work
per
Hour
/
Day
Week
Regular (Over 150 days)
Temporary (3 days or less)
Regular or Temporary (4-150 days)
Month
Year
Other
/
35. Which shift(s) are you willing to work? (Check all that apply)
First
36. *36. How do you prefer to be contacted? (Check all that apply)
Mail
Primary Phone
Alternate Phone
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
Job Title:
Experience in this job: Years
Job Title:
Experience in this job: Years
Months
Months
Months
Second
Fax
Third
E-Mail
Split
Rotating
Any
Acceptable Job Locations
*39. I am willing to work within the following zip codes or states or countries:
Choose either A. B, orC. 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
A. Within 5 10 25 50 100 miles of zip code
B.
C.
Within 5 10 25 50 100 miles of zip code
B.
C.
Within 5 10 25 50 100 miles of zip code
B.
C.
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 experiencef 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
State
Country, if not US
Start Date (mo./yr.)
End Date (mo./yr.)
City
Wage $
Supervisor
Phone No.
per hr/day/wk/mo/yr/other Reason for Leaving
Job Duties:
Job Title
* Employer
Address
State
Country, if not US
Start Date (mo./yr.)
End Date (mo./yr.)
City
Wage $
Supervisor
Phone No.
per hr/day/wk/mo/yr/other Reason for Leaving
Job Duties:
Job Title
* Employer
Address
State
Country, if not US
Start Date (mo./yr.)
End Date (mo./yr.)
City
Wage $
Job Duties:
Supervisor
per hr/day/wk/mo/yr/other Reason for Leaving
Phone No.
Driver’s License
41. Do you have a driver’s license?
What type of license do you have?
Yes
No If you answered “No,” go directly to question 44.
Class A (Tractor Trailer)
Class C (Light Truck Comm.)
Class D (Operators)
Class M (Motorcycle)
Class B (Truck/Bus)
Class Cn (C-non-CDL)
Class E (Taxi)
Issuing State
Endorsements:
Passenger Transport
School Bus
Hazardous Materials
Doubles/Triples
42. Do you need public transportation to get to a job?
43. Do you own or have access to a vehicle?
Yes
No
Certificates/Licenses
44. Do you have an occupational certificate or license?
Yes
/
Additional Certificate/License:
Issue Date (Mo/Yr):
/
No If you answered “No,” go directly to question 45.
Issuing Organization or Locaility:
State:
Country:
State:
Issuing Organization or Locaility:
Country:
Schools
45. Do you have a degree, diploma, or educational certificate?
Course of Study:
Issuing Institution:
Motorcycle
No
Yes
Certificate/License:
Issue Date (Mo/Yr):
Tank Vehicles
Degree:
State:
Additional Degree, Diploma or Educational Certificate:
Course of Study:
Degree:
Issuing Institution:
State:
Yes
No If you answered “No,” go directly to question 46.
Date Completed (Mo/Yr):
Country:
/
Date Completed (Mo/Yr):
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, aut omobile
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:
Customer Initial Assessment Form
Your Name:
1. Do you have a resume available to give to prospective employers?
Yes
No
2. Do you have regular access to an email account?
Yes
No
3. Would you like information about assistance with creating or revising a resume?
If you feel that you do not need a resume, please explain below.
Yes
No
4. Is it likely that you will be returning to work for your former employer soon?
Yes
No
If Yes, please estimate your return to work date (month/day/year):
/
/
5. Please list below any personal (education, transportation, child care, medical, etc.) circumstances which are
causing you difficulty in finding or maintaining employment.
6. Do you have United States Military Service (are you a Veteran)?
Yes
No
7. Are you comfortable using a computer to search for work?
Yes
No
8. Which of the following is your preferred method of job search? Please check one.
Newspaper
Networking
Internet
Union
Staffing/Placement Agency
Other
9. Are you interested in training (college, trades, etc.)? If Yes, please explain below.
Yes
No
10. Are there other concerns you would like to discuss? If Yes, please explain below.
Yes
No
DOL USE:
JSRS
CDS
Agency Referrals
ACCES-VR
NCCC Enrichment Center
Other(s):
Niagara County Employment & Training
Orleans-Niagara BOCES Continuing Education Center
Job Matching Skills (Please check the skills that you currently have)
Name:
COMPUTER
Software
Adobe:
Hardware
ADMINISTRATIVE/BOOKKEEPING
Administrative Assistant
Bookkeeping
Multi-line Phones
Assembly
Accounts Receivable
Call Center
Office Management
Acrobat
Illustrator
InDesign
Help Desk
Installation
LAN
Accounts Payable
Billing
Collections
Communication
Customer Service
Payroll
Purchasing
Reception
PageMaker
Photoshop
MACs
Mainframe
PCs
Insurance
Medent
Medical Billing
Desktop Publishing
Dispatch
Executive Secretary
Scheduling
Shipping/Receiving
Switchboard
PBX
Administrator
Repair
Servers
Medical Coding
Human Resources
Transcription
Medical Records
Medical Terminology
Import/Exp/Customs
Legal Terminology
Typing:
Microsoft:
Access
Excel
Outlook
PowerPoint
Troubleshooting
Project
WAN
Publisher
Programming
Electrician
A+, A++
BASIC
C, C++
COBOL
dBase
Fortran
FoxPro
CAD
HTML
5S
PCA
Lexis-Nexis
MAPICS
Novell
Java
JavaScript
Pascal
ASE
ISO 9000,9001, 9002
Kaizen/Kanban
HHA
Oracle
Paradox
Peachtree
PeopleSoft
Quark XPress
PHP
PowerBuilder
Visual Basic
OSHA
Six Sigma
Welder
Operating
Systems
QuickBooks
Quicken
SAP ERP
DOS
LINUX
MAC
UNIX
Windows
Other
Digital Marketing
Web Design
HazMat/Asbestos
Mason
Operating Engineer
Plumber
Sheet Metal Worker
Medical
Approach
Freelance
Notes
123
Smart Suite
WordPro
AutoCAD
QuattroPro
wpm
Logistics
LICENSES/CERTIFICATIONS
Construction
Health Care
Word
Lotus:
Medical-Specific
Manufacturing
Doctor
PA
NP
RN
LPN
Medical Assistant
CNA
Auxiliary:
Education
College Instructor
Preschool Teacher
Teacher-List Certifications
Teacher Aid/Tutor
Professional
Accountant/CPA
Advertising/Marketing/PR
Auditing
Human Services
Dental Assistant
Dental Hygienist
Dietician
Lab Tech
Pharmacist
Biologist
Chemist
Engineer:
Financial Advisor
Grant Writer
Counselor/LMHC
Pharmacy Tech
Human Resources
Direct Care Aid
Social Worker/MSW
Physical Therapist
PTA
Occupational Therapist
Insurance Agent
International Relations
Lab Tech:
OTA
Speech Therapist
Radiologist
Radiology Tech
Management
MBA/Business Admin
Project Management
Quality Control/Assurance
Experienced with:
Addicted
Children
Dev. Dbl.
Disabled (physical)
Elderly
Mentally Ill
TBI
LANGUAGES
Arabic
French
Polish
Russian
Spanish
MANUFACTURING
Assembly (electronics)
Assembly (general)
Assembly (skilled)
Blueprints
CAD
CNC Operation
DC Drivers
Electrical Codes
Electrical Test Equipment
Hydraulics
Install Elec-Mech Controls
Own Tools
Robotics
Shipping/Receiving
Schematics
Shop Math
Soldering
SOP
Baker
Banquet
Bartender
Chef
Counter Worker
Dishwasher
Host/Hostess
Kitchen Helper
Manager
Prep Cook
CNC Programming
Crane Operation
Cutting/Combination Cutting
Drill Press
Fabrication
Forklift/Tow Motor
General Labor
GMP
Grinder- set up
Grinder- operate
Machine Operator
Material Handling
Metal Worker
Micrometers
Military Specifications
Milling Machine- set up
Milling Machine- operate
Millwright
Molding
OSHA
Stamping
Spray Paint
Sewing: clothing or industrial
Team Production
Technician:
Through-Hole Circuit Boards
Tool & Die Maker
Utility
Warehouse
Sous Chef
Server
Heavy Equipment Operator
Inspection
Lathe- set up
Lathe- operate
Packing
PLC
Press Bake
Production Control/Planning
ARC
ASME Code
MIG
Robotic
Production Laborer
TIG
Quality Assurance/Control
Structural
FOOD SERVICE
CONSTRUCTION
Buildings:
Commercial
Residential
Carpentry:
Rough
Finish
Blueprints
Bricklayer
Bridges/Roads
Cabinetry
Drywall Hanger
Electrician
Heavy Equip Operator
HVAC
Mason
Painter/Paperhanger
Pipefitter
Plasterer
Plumber
Roofer
Maintenance/Tech Repair:
110/220
RETAIL/SALES
CUSTOMER SERVICE
Cashier
Customer Service
Inventory
Loss Control
Ordering
Receiving
Retail Management
Sales:
Inside
Outside
Retail (sales floor)
Telephone
Service Desk Clerk
Shift Supervisor
Stock/Merchandising
Telemarketing
MEDICAL
Welding:
AUTOMOTIVE
AED/CPR
Assisted Living
Clinical:
EEG/EKG
EMT
Emergency Room
First Aid
ICU
ASE Certified Mech.
Auto Body Repair
Auto Mechanic
Brakes
Detailing
Diagnosis/Estimates
Diesel Mechanic
Engine Repair
In-home Care
Institutional Care
Long Term Care
Mental Health
Nurse Aid (not cert)
Phlebotomy
Skilled Nursing
Glass
Inspection
Oil Change
Spray Painter
Tires
Transmission
Truck Mechanic
HOSPITALITY
Building Maintenance
Casino Gaming
Front Desk
Grounds Maintenance
Housekeeping
Janitor
Manager
Night Auditor
EQUAL
OPPORTUNITY
is THE LAW
It is against the law for all recipients of Federal financial assistance to discriminate on the following basis:
Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation
or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA). on
the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her
participation in any WIA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following
areas: Deciding who will be admitted, or have access, to any WIA Title I-financially assisted program or activity; providing
opportunities in, or treating any person with regard to such a program or activity; or making employment decisions in the administration
of; or in connection with such a program or activity.
What to Do If You Believe You Have Experienced Discrimination
If you think you have been subjected to discrimination under a WIA Title I-fmancially assisted program or activity, you
may file a complaint within 180 days from the date of the alleged violation with either:
Director
Division of Equal Opportunity Development New York State Department of
Labor State Office Campus, Building 12, Room 540 Albany, New York
12240 usaada@labor.statc.ny.us
PHONE: (518) 457-1984 (TDD) 1-800-662-1220
(VOICE) 1-800-421-1220
or you may file a complaint directly with:
Director
Civil Rights Center (CRC)
U.S. Department of Labor 200 Constitution Avenue, N W Room N-4123
Washington, D.C. 20210
If you file your complaint with the recipient, you must wait either until
the recipient issues a written Notice of Final Action, or until 90 days have
passed (whichever is sooner), before filing with the Civil Rights Center (see
address above). If the recipient does not give you a written Notice of Final
Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice
before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other
words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written
Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC.
You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action
DEOD 3121 (9/13)
Equal Opportunity Employer/Program.
Auxiliary aids and services are available upon request to individuals with disabilities
.