(DRAFT AJC Form with Veteran info) Date(Required) Month Day Year Preferred Service Location (select one):(Required) American Job Center, Marion, Illinois One-Stop Business & Employment Center, Mt. Vernon, Illinois Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone Number(Required)Secondary Phone NumberEmail(Required) Enter Email Confirm Email Date of Birth(Required) Month Day Year I live in the following County (check one):(Required) Franklin Jackson Jefferson Perry Williamson Other Have you done farm work in the last 24 months, or are you a dependent of someone who has done farmwork in the last 24 months?(Required) YES NO Have you served in the military, or are you a spouse of a Veteran?(Required) YES NO Veteran (Section A)Before completing Veteran Sections A, B, C, and D, shown below, please download and review the Veteran Eligibility Triage Form Definitions Document (PDF file, 276 KB).Dates Served (From: — To:)What was your Character of Service at discharge? Honorable Dishonorable Other Veteran (Section B)If you check any of the boxes or answer "YES" to any of the questions in this section, you may be eligible for additional services, if desired.Are you an eligible VETERAN who served between the years 1961-1975 and meets one of the following: I served in the Republic of Vietnam between 2/28/1961 and 5/7/1975 I served (regardless of location) between 8/5/1964 and 5/7/1975 Are you an eligible VETERAN aged 18 to 24? YES NO Are you a Transitioning Service Member who attended a Transition Assistance Program (TAP) workshop, and: Are between the ages of 18-24 years old? An active duty service member being involuntarily separated through a service reduction-in-force? Do not meet career readiness standards (CRS)? Are you a wounded, ill, or injured Service Member receiving care at a Warrior Transition Unit (WTU) or Military Treatment Facility (MTF)? YES NO Are you a CAREGIVER for a wounded, ill, or injured Service Member receiving care at a WTU or MTF? YES NO Veteran (Section C)If you check any of the boxes in this section, please proceed to Section D and mark all applicable options.Are you a VETERAN who: Served on active duty for a period of MORE than 180 consecutive days (including Title 10 orders)? Was discharged or released from active duty because of a service-connected disability? Served in support of a conflict or campaign? Was released from service under a Sole Survivorship discharge? Are you the SPOUSE of a Veteran who: Died of a service-connected disability, or while a disability was being evaluated? Has been classified as a missing, captured, or detained Service Member? Is 100% Total and Permanently Disabled? Veteran (Section D)If you check any of the boxes in the section below, you may be eligible for additional services, if desired.Are you an eligible VETERAN or eligible SPOUSE (check all that apply): 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 Select AllI need help with the following (select all that apply):EDUCATION Receiving VA disability compensation or have a claim pending to receive compensation? Who is Homeless/At-Risk — or lacks a fixed, regular nighttime residence, or is fleeing a violent situation? Recently separated service member unemployed for 27 or more weeks in the previous 12 months? Who is incarcerated or has ever been incarcerated? Who lacks a High School Diploma or equivalent certificate? Who is low income, receiving public assistance, housing, food, TANF, or other programs? EMPLOYMENT Deciding on a career Preparing a resume Filling out an application Preparing for an interview finding a job Select AllPERSONAL BARRIERS 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 Select AllLEGAL SERVICES Expunging records Sealing criminal records Getting a petition for "Certificate of Good Conduct" Select AllAUTHORIZATION TO RELEASE INFORMATION(Required) I agree that American Job Center partners may share my information. NOTE: Referrals will be sent within 24 hours.Signature(Required)By signing and/or submitting this form, customer has self-attested and acknowledges their status as listed in the sections above.Comments/Special InstructionsCAPTCHA
