GUAM ONE-STOP CAREER CENTER

COMMON REGISTRATION FORM

Instructions: Please complete this form as completely as possible to the best of your ability. If you do not understand a question, please leave it blank and
the staff will assist you. NOTE: This is not an employment application

__________________________
_______________________________
Social Security Number

_______________________________
Drivers License Number

Drivers License Type

________________________________ _______
___________________________________
___________
First Name:
M.I.
Last Name:
Suffix
_________________________________
Male_____ Female_____ Registered for Selective Service__________
Date of Birth (Month/Day/Year)
(Males Only)
Yes or No
Place of Birth: ___________________________
Citizenship

______ U.S. Citizen

______ Eligible Non-U.S. Citizen Alien Registration Number____________ Expiration Date: _________
______ Other: Specify _______________________ I-94 or Passport No. ___________________________
Country of Issue: __________________________

Veteran Status: __________ Yes (Must Provide DD 214) ________No

Person with a Disability: ______ Yes ______ No
Dislocated Worker: _____ Yes (Must Provide Employer Verification letter) ______No
Mailing Address:
Residential Address:
Contact Number:

House or Box No. __________________________________

Street, City, State, Zip ________________________________
House No._________________________________________
Street, City, State, Zip ________________________________
__________________ __________________ ___________________
Home Phone
Work Phone
Fax No.
__________________ __________________ ___________________
Cellular Phone
Pager Number
Nearest Relative

EDUCATION:
In School:

__________________ __________________ ___________________

Email Address
Other Number
Other Number
Last Grade Completed In School: _________
________ No
_________ Yes Specify School: ________________________

Highest Education Level Achieved:

______ Not a High School Graduate
______ High School Graduate or GED

_______ Post Secondary Degree or Certification

Schools Attended:
School Name: ________________________________School Name: ___________________________________
School Address: City, State ______________________School Address: City, State _________________________ Date
Started: __________ Date Ended: ____________
Date Started: _____________ Date Ended: ____________
Grade Attained: ________ GPA: _______
Grade Attained: _________ GPA: ________
Degree/Diploma/License: _______________________Degree/Diploma/License: __________________________
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Major Field of Study: ___________________________Major Field of Study: _____________________________

FAMILY:
Marital Status _______ Single
_______ Married
Head of Household: ______ Yes
Race:

_____
_____
_____
_____
_____
_____
_____
_____

_______ Divorced
_______ Separated
_______ Widowed
______ No

Number In Family:
_________
Number in Household: _________
Dependents under 18 _________

Hispanic or Latino
White
American Indian/Alaska Native
Black/African-American
Hawaiian Native or other Pacific Islander: Please Specify:______________________________________
Asian Please Specify: ___________________________________________________________________
More than one Race. Please Specify: _______________________________________________________
Other Please Specify: ___________________________________________________________________
(Check each below that applies to your ability with the language)

Primary Language:

___________________________

Secondary Language:

_____________________________

________
Speak
________
Speak

________
Read
________
Read

________
Write
________
Write

EMPLOYMENT:
Are you currently employed:

______ Yes

______ No

Unemployment Insurance (UI) Status

______ Not a Claimant nor an Exhaustee
______ Yes, a UI Claimant/Exhaustee

Total gross income earned in the last year: ___________

Employment Details:
A. Company Name:
Address:
Telephone:
Start Date:
Number of Months with Company:
Reason For Leaving:

Job Title:
Supervisor:
Wages (hourly):
End Date:

Equipment & Tools Used:

B. Company Name:
Address:
Telephone:
Start Date:
Number of Months with Company:
Reason For Leaving:

Job Title:
Supervisor:
Wages (hourly):
End Date:

Equipment & Tools Used:

C. Company Name:
Address:

Job Title:
Supervisor:
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Telephone:
Start Date:
Number of Months with Company:
Reason For Leaving:

Wages (hourly)
End Date:

Equipment & Tools Used:

Are you currently receiving or have you ever received public assistance? _____ Yes

_____ No

Are you available to work: (check all that apply)

____ Full Time ____ Part Time ____

Flexible Hours

Do you have transportation to work?

____ Yes

Do you have childcare available so you can work?

Check all equipment you can operate: _____ Computer
_____ Fax Machine
Other Additional Skills:
Type Of Job you Prefer:
Training Interest:

____ Temporary Work ____ Volunteer Work

____ No
____ Yes

____ No

_____ Typewriter

_____ Photocopier

Heavy Equipment / Special Tools : Specify ______________________________

__________________________________________________________________
1st _______________
1st _______________

Are you applying for the Job Corp Program?

2nd _______________

3rd _____________

2nd _______________

____ Yes

3rd ____________

____ No

Contacts:
First Name

Last Name

Relationship

Address

Telephone

1. ______________________________________________________________________________________
2.______________________________________________________________________________________
3. ______________________________________________________________________________________

The information I have provided is true, complete and correct to the best of my knowledge. I agree to allow sharing of the
above
and other relevant in information with other agencies for the purpose of assisting me attaining my educational, training, and / or
employment goals and supportive services. I authorize my former employers to release, without liability, any information in the
possession relevant to my past performance as their employees. I also authorized any verification of all statements made.
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In addition, I hereby authorize both Department of Labor and Agency of Human Resources Development to obtain wage
information from the Department of Revenue & Taxation for reporting purposes only.
I understand that I am being referred to the program indicated below to assist me with my needs.
Signature: ____________________________________________

Date: ___________________________

For Staff Only

Received By: ____________________________________________

Date: _______________________

Staff Name & Agency

Customer is Referred to the following program(s). Programs should indicate date customer was received by their program.
WIA _______________
Date
Welfare to Work ______________
Date
GES ______________
Date
SCSEP ______________
Date
TANF ______________
Date
CSBG (Child Care, Trans. Wk Clothing) _______________
Date
Foster Care _______________
Date
Work Activities under Food Stamp Act (ETP)
_______________
Date
Family Self Sufficiency Program __________________
Date
Community Development Block Grant ____________________
Date

ROSS _______________
Date
Section 3 Program ________________
Date
MOD _______________
Date
Vocat. Rehab. Svcs. For Ind. W / Disabilities

________________
Date
Suptd. Employment. Svcs. For Ind. W/ Significant Disabilities
________________
Date
GCC: Specify: _________________
Date
School To Work Transition Program __________________
Date
Job Corps ________________
Date
Other, Specify ______________________________
________________
Date

For Staff Only

Received By: _____________________________________________

Date: _____________________

Staff Name & Agency

Customer is Referred to the following program(s). Programs should indicate date customer was received by their program.
WIA _______________
Date
Welfare To Work ______________
Date
GES ______________
Date
SCSEP ______________
Date
TANF ______________
Date
CSBG (Child Care, Trans. Wk Clothing ) _______________
Date
Foster Care _______________
Date
Work Activities Under Food Stamp Act ( ETP )
_______________
Date
Family Self Sufficiency Program __________________
Date
Community Development Block Grant ____________________
Date

ROSS _______________
Date
Section 3 Program ________________
Date
MOD _______________
Date
Vocat. Rehab. Svcs. For Ind. W / Disabilities

________________
Date
Suptd. Emplymt. Svcs. For Ind. W/ Significant Disabilities
________________
Date
GCC: Specify: _________________
Date
School To Work Transition Program __________________
Date
Job Corps ________________
Date
Other, Specify ______________________________
________________
Date

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