Orleans Youth Employment Program
Applicant Name: ____________________________________
Race White Black or African American Hispanic or Latino
Alaskan/American Indian Asian Hawaiian/Pacific Islander Other
Note: Ethnicity question is voluntary. Information will be kept confidential and is intended for use solely in connection with rec-
ord keeping and affirmative action requirements. You will not be penalized for refusal to answer.
Have you ever been convicted of a crime? Yes No
If yes, explain in full: _______________________________________________________________________________________________
Males-18 years and older, are you registered for Selective Service? Yes No If no, register at sss.gov
High School _____________________________ Grade ____ Do you have IEP 504 AIS Vocational program _________________________
Earned a high school diploma or equivalency diploma? Yes No
SKILLS and INTERESTS
List your skills and abilities you have learned in a job, at home, as a chore, or as a hobby.
List your volunteer and/or community service performed: _______________________________________________________________
Which type of worksite do you prefer?
Office Retail Assembly and Production Recreation Program
Outdoor Maintenance Food Service Day Care Center Center for Disabled Adults/Youth
Indoor Maintenance Nursing Home Hospitality Other ___________________
Which of the following high demand jobs are you interested in learning more about?
Advanced Manufacturing: HVAC Welding Optics Machining Auto Mechanic
Health Care: Home Health Aide (HHA) Certified Nursing Aide (CNA) Licensed Practical Nurse (LPN) Registered Nurse (RN)
Agriculture Truck Driving Starting your own business
If you could have a job right now, what would it be? _____________________________________________________________________________
What job do you want 5 years from now? __________________________Why? _______________________________________________________
TRANSPORTATION: How will you get to a job or appointment? Bicycle Parents Own Car Public Transportation Walk
Do you have a driver’s license? Yes No If No, do you have a Learner’s Permit? Yes No
WORK HISTORY: ( See Attached Resume)
Job Title _____________________________________ Employer _________________________________________________
State ________ Country, if not US ______________________
Start Date _____/_____/_____ End Date __/__/___
Reason for leaving _____________________________________
Job Duties __________________________________________________________________________________________________________