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Home
Free Services
Service Center Hours
Free Online Learning
Employer Services
Career Specialists
Film Industry Support
Production Assistant (PA)Training
Google Certificate Program
Job Search Help
Job Skills Classes
Seniors 55+ Employment
Veterans' Employment
Veterans' Housing
Veteran Family Services
Program Surveys
Shop
Store Locations
Become a VIP Shopper
DIY
Return Policy and Fees
Shopper Survey
Donate
Donation Centers
Schedule Home Pickup
Donate Stuff
Donate Money
Donate Vehicles
E-Waste Recycling
Our Donors
Donor Survey
Jobs
About Us
Contact Us
Frequently Asked Questions
Hours of Operation
Leadership Team
Our History
Resources
Sustainability
Transparency
What We Do
Blog
Events
Career Fairs
Community Classroom
Production Assistant Training
Job Skills Classes
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Application for Google Certificate Program
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Indicates required field
Name
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First
Last
Social Security Number:
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Date of Birth
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Address
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Line 1
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City
State
Zip Code
Country
Marital Status:
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Single
Married
Divorced
Widowed
Single, living with partner
Email
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Phone Number
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Last day of most recent employment, if currently employed, use today's date.
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Wage's per hour:
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Hours per week:
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Have a current resume? Upload File or bring a printed copy to first meeting.
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Max file size: 20MB
Financial Wellness
Are you receiving any of the following benefits and income supports? Check all that apply.
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Child Care Subsidy
Earned Income Tax Credit
Free or Reduced Price Lunch
Head Start
LIHEAP (Utility Bill Assistance)
Medicaid
Rental Housing Assistance/Subsidy (Section 8)
SNAP (Food Assistance/Food Stamps)
TANF (Cash Assistance)
Unemployment
WIC
Not Applicable/Not Receiving Any of the Above
Financial Capability
Over the last 3 months, have you followed a personal budget, spending plan, or financial plan?
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Yes
No
How confident are you in your ability to achieve a financial goal you set for yourself today?
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Not at all confident
Somewhat confident
Confident
Have you set aside funds that would cover your expenses for 3 months if you or someone in your family lost a job, got sick or had another emergency?
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Yes
No
Do you currently have an automatic deposit or electronic transfer set up to put money away for a future use such as saving for retirement or education?
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Yes
No
Over the past 3 months, would you say your household's spending on living expenses was less than its total income?
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Yes
No
Don't Know
In the last 3 months, have you paid a late fee on a loan or bill?
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Yes
No
How would you rate your current credit record?
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Very Bad
Bad
About Average
Good
Very Good
Don't Know
Healthy and Wellbeing
Healthcare
Select the statement that best reflects your current situation:
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No medical coverage with immediate need
No medical coverage and great difficulty accessing medical care when needed
Some members (e.g. children) have medical coverage
All members can get medical care when needed, but may strain budget
All members are covered by affordable, adequate health insurance
VA medical coverage
Health Status
Select the statement that best reflects your current situation:
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My immediate family or I have physical, mental, or substance use concerns that PREVENT my employment or daily life activities.
My immediate family or I have physical, mental or substance use concerns that OFTEN INTERFERE with my employment or daily life activities.
My immediate family or I have physical, mental or substance concerns that SOMETIMES AFFECT my employment or daily life activities.
My immediate family or I have physical, mental or substance concerns that AFFECT my employment or daily life activities.
My immediate family and I are healthy and participate in preventive health measures (examples include annual check-ups, screenings, vaccinations).
Work and Life Supports
Food Security
Select the statement that best reflects your current situation:
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No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost food.
Household is on food stamps.
Can meet basic food needs, but requires occasional assistance.
Can meet basic food needs without assistance.
Can choose to purchase the food that the household desires.
Housing Stability
Select the statement that best reflects your current situation:
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Homeless or threatened with eviction.
In transitional, temporary (short-term) or low quality housing; and/or current rent/mortgage is unaffordable (over 30% of income).
In stable housing that is safe, but only barely adequate (housing may have small problems).
Household is in safe, subsidized (receiving assistance to pay rent) housing with no serious problems.
Household is safe, unsubsidized (no rent assistance) housing with no serious problems.
Transportation Access
Select the statement that best reflects your current situation:
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No access to transportation (public or private) or may have car that is inoperable (can't be driven).
Transportation is available, but unreliable, unpredictable, unaffordable; or may have car but no insurance, license, etc.
Transportation is available and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured.
Transportation is generally accessible to meet basic travel needs.
Transportation is readily available and affordable; car is adequately insured.
Recidivism
Have you ever been convicted of a crime?
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Yes, felony
Yes, misdemeanor
Yes, multiple misdemeanors
None
Have you been convicted of a crime in the last year?
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Yes
No
Have you been incarcerated in the last year?
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Yes
No
Legal Issues
I have legal problems that may interfere with my work, education or quality of life.
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Yes
No
Family Care
Select the statement that best reflects your current situation:
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Needs dependent (child or elder) care, but none is available or accessible and/or dependent is not eligible.
Dependent care is unreliable or unaffordable, not enough supervision is a problem for what care is available.
Affordable subsidized (assistance in paying for) dependent care is available, but limited.
Reliable, affordable dependent care is available, no need for subsidies (assistance in paying for care).
Able to select quality dependent care of choice/No care needed.
Clothing
Select the statement that best reflects your current situation:
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No clothing or seriously inadequate clothing. (For example, no coat for winter months, shoes with holes in them or soles lacking, not sufficient to assure clean clothes on a daily basis.) Unaware of where to access assistance.
Very limited knowledge of resources for low-cost or free options to obtain clothing.
Occasionally relies on community clothing banks. Has limited knowledge about community resources and/or financial resources to obtain clothing.
Usually has the financial resource to purchase appropriate clothing. Aware of what is appropriate for work environment.
Always has a financial resource to purchase appropriate clothing of choice. Aware of what is appropriate for work environment.
Which Google Certificate is most interesting to you?
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IT Support Specialist
Data Analytics
I am 18 years of Age or Older
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Yes
No
Gender
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Female
Male
Transgender
Non-Binary
Other
Prefer Not to Say
Race
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Caucasian or White
Black or African American
American Indian/Alaskan Native
Asian/Native Hawaiian/Other Pacific Islander
Prefer Not to Identify
Ethnicity
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Hispanic/Latino Ethnic Origin
Not Hispanic/Latino
Prefer Not to Identify
Number of people in your household/family?
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Veteran and Military Family Status
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Veteran/History of Military Service
Member of military family (immediate family member in the military or a Veteran)
Not a Veteran or member of military family
If a Veteran, what was your Military Discharge Status?
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Honorable
General, Less Than Honorable
Bad Conduct, General Court Martial
Bad Conduct, Special Court Martial
Dishonorable
Other
If a Veteran, select Veteran Status Categories:
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Post 9/11
Veteran with Service-Connected Disabilities
Annual income:
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$0-$9,999
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 +
Select all categories that apply to you:
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History of Substance Abuse
Dislocated Worker
Non-English Speaker/English as a Second Language
Lack of Literacy
Immigrant/New American
Refugee
LGBTQ2SIA+
Single Parent
None of these
Disability categories:
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Blindness or Other Visual Impairment
Deafness or Hard of Hearing
Other Physical Disability
Neurological Disability
Learning Disability other than Autism
Developmental Disability other than Autism
Autism
Psychiatric Disability
Emotional Disability
Other Disabling Condition
None of these
Education Level (one choice only)
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No formal schooling completed
Completed 8th grade
Less than high school diploma
High School Diploma GED/high school equivalency
Postsecondary non-degree award
Associates degree
Bachelor’s degree
Graduate degree
Are you currently enrolled in any of the following?
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High School Diploma GED/high school equivalency
Postsecondary non-degree award
Associates degree
Bachelor’s degree
Graduate degree
None of these
Have you received a certificate, or a credential issued by an industry or professional organization or certifying body?
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Yes
No
How many degrees, certificates, or credentials related to the same occupation or industry do you have?
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List all degrees, certificates, or credentials issued by an industry or professional organization or certifying body.
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Do you, or someone in your household, own any of the following? Select all that apply.
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Desktop computer or laptop
Smartphone
Tablet or other wireless computer
Another type of computer
Please specify
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*
None of these
Do you have access to the Internet in your current living space?
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Yes, a cellular data plan for a smartphone or other mobile device
Yes, Broadband (high speed) Internet service such as cable, fiber optic, or DSL service installed
Yes, Satellite Internet service installed
Yes, Dial-up Internet service installed
Yes, Other service – please specify:
Please specify
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*
No access to the Internet in my current living space
If the above is checked: how many miles to your nearest public access to the Internet?
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Select the answer that better describes you:
I will be able to achieve most of the goals I have set for myself.
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Strongly Agree
Agree
Neither agree or disagree
Disagree
Strongly Disagree
When facing difficult tasks, I am certain that I will accomplish them.
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Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
In general, I think I can obtain outcomes that are important to me.
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Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
I believe I can succeed at most any endeavor (anything) I set my mind to.
*
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
I will be able to successfully overcome many challenges.
*
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
I am confident that I can perform effectively (do well) on many different tasks.
*
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
Compared to other people, I can do most tasks very well.
*
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
Even when things are tough, I can perform quite well.
*
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
Select the answer that better describes you:
New ideas and projects sometimes distract me from previous ones.
*
Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
Delays and obstacles (things that get in the way) don’t discourage me.
*
Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
I have been obsessed with (constantly thinking about) a certain idea or project for a short time but later lost interest.
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Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
I am a hard worker.
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Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
I often set a goal but later choose to follow a different one.
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Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
I have difficulty keeping my focus on projects that take more than a few months to complete.
*
Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
I finish whatever I begin.
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Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
I am hard working and careful.
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Very much like me
Mostly like me
Somewhat like me
Not much like me
Not like me at all
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