INTAKE FORM Complete and submit the preliminary application form below to find out if you are eligible to receive American Job Center services: Date* Month Day Year Preferred Service Location (select one):* American Job Center, Marion, Illinois One-Stop Business & Employment Center, Mt. Vernon, Illinois Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Primary Phone Number*Secondary Phone NumberDate of Birth* Month Day Year I live in the following County (select one):* Franklin Jackson Jefferson Perry Williamson Have you served in the military, or are you a spouse of a veteran?* YES NO Have you done farm work in the last 24 months, or are you a dependent of someone who has done farm work in the last 24 months?* YES NO I need help with the following (select all that apply):EDUCATION Select All Finishing my High School education Improving my reading, writing, and/or math skills Updating skills for a job Enrolling in college Educational expenses Learning to speak English EMPLOYMENT Select All Deciding on a career Preparing a resume Filling out an application Preparing for an interview Finding a job PERSONAL BARRIERS Select All Temporary cash assistance (TANF, AABD) Food assistance (SNAP) Medical assistance Transportation to work and/or school Disability services Unemployment Insurance (UI) Paying rent Paying utility bills LEGAL SERVICES Select All Expunging records Sealing criminal records Getting a petition for "Certificate of Good Conduct" AUTHORIZATION TO RELEASE INFORMATION:* I agree that American Job Center partners may share my information.NOTE: Referrals will be sent within 24 hours.Signature*Comments/Special Instructions:CAPTCHACommentsThis field is for validation purposes and should be left unchanged.