Education Opportunity Questionnaire

Each provider within the Gulf Coast Education Opportunity Consortium is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. (Please request reasonable accommodations a minimum of two business days in advance.) Relay Texas Numbers: 1.800.735.2989 (TDD) 1.800.735.2988 (voice) or 711

First Name*

Last Name*

Birthday*

Street Address*

City*

State/Province*

Email*

Phone Number*

Select Preferred Contact Method*

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Primary Language*

Secondary Language*

Are you currently employed?*

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Are you a veteran?*

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Are you able to legally work in the United States of America?*

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Have you been convicted of a felony?*

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Have you been convicted of a misdemeanor?*

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Do you currently receive unemployment benefit services?*

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Which of the following Employment and/or Financial Services are you seeking? (Check all that apply)*

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Are you interested in Employment Services in any of the following areas? (Check all that apply)*

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Which of the following Financial Services would benefit you? (Check all that apply)*

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Are you interested in any of the following services? (Check all that apply)*

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Notes (Office Staff Only)

Statement of Release of Information*

The individual hereby authorizes the release of and sharing of all required and pertinent information between the Workforce Solutions and its partners. All release information is to be used strictly for the purpose of service planning, delivery and tracking. Released information will remain confidential. This information will be used solely to assess, plan, and support your efforts toward educational and financial stability, and will not be sold or used for commercial purposes.

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Staff Name*

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