456 Ravenwood Circle                                                               www.workman-associates.com

Neosho, MO  64850                         (417) 455-1400                                         (417) 455-1405 Fax

 

 

 

 

 

Directions:  Select Print from your browser.  Complete the form and mail or fax it to the address above.  We will call you for more information after we receive this information.

Name:                                                                 Phone:                                       Date:

 

Address: 

 

Date of Birth:                                        Soc. Security #: 

 

Others in household: for wages and income (unearned) circle Y for yes and N for no

Name:                                 Relationship            Age               Wages        Income

                                                                                                        Y      N           Y      N

                                                                                                        Y      N           Y      N

                                                                                                        Y      N           Y      N

                                                                                                        Y      N           Y      N

 

Type of work desired:

# of Hours per week:           $ per hour desired:

Preferred work schedule: 

Do you have reliable transportation?                                   Y    N

Are you willing to commute?                                                  Y    N    How far?  

Do you need a job located on the bus route?                    Y    N

Can the job include overnight travel?                                  Y    N    How frequent?

 

Have you ever been convicted of a felony or misdemeanor?         Y      N

 

Current amount of social security benefit:  $             Medicare?      Y      N

Medicaid?     Y      N         Other health insurance?

Do you get food stamps?     Y      N

 

Please list any concern that you have about returning to work.

 

 

Please list the reasons that you want to re-enter or enter the workforce.

 

 

If you already have a resume, please attach it.

By signing this application for services from Workman & Associates through the Ticket to Work program,  I understand that I am agreeing for my needs to be reviewed to      determine if they can be of assistance to me.  I understand that I am under no obligation to assign my ticket to them at this time.  If I chose to assign my ticket to them, then services are provided at no cost to me.

 

Your signature:___________________________________________ Date:___________