Full Legal Name Preferred Name Preferred Pronoun Date of Birth Social Security Number Are you experiencing homelessness? Mailing Address

Mailing City

Mailing State

Mailing Zip

Mailing County

Phone Email

What is your preferred language? Do you need an interpreter? Yes No

Are you a citizen of the United States? Yes No – Eligible Non-Citizen No – Non-Citizen, not authorized to work Are you a Veteran? Yes No Eligible Spouse of a Veteran How did you hear about us? DEED Website Flyer Career Force Virtual Career Fair Unemployment Anoka County Website Counselor Agency or School Referral Veteran Counselor Other Friend/Relative What is your primary interest at this time? Getting a full-time job with little or no training Enrolling in training to get a certificate or degree before seeking full-time employment Getting help finding a part time job Other (please describe) Have you applied for, do you receive, or have you exhausted unemployment benefits? Yes No Do you have an employment counselor? Yes No

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I understand that I am being asked to provide private information to the Job Training Center to enable the Job Training Center to assist me. I understand this information may be shared with others as allowed by law but only after I have received and signed the full Department of Employment and Economic Development Notice How We Use Your Personal Information. I acknowledge and agree that all data I enter will be available to the Anoka County Job Training Center. I further acknowledge and understand that all data entered is subject to the Minnesota Government Data Practices Act.

I acknowledge that by electing to receive my information via email in a non-secure manner that the information will not be encrypted, and that it could be intercepted & viewed by a third party. Anoka County Job Training Center is not responsible for unauthorized access to your information while in transmission to the email address you designated above.

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