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Workability III Services Application Form

You must have an open Department of Rehabilitation (DOR) file to qualify. If you have any questions, contact Workability III.

Please provide as much information as possible.

Asterisk (*) indicates a required field.

Personal Information

Contact Information

* First Name:
* Last Name:
* Street Address:	Street Address line 2:
* City:
* State/Province:
* ZIP/Postal Code:
* Telephone Number:	(Include area code.) What is this telephone number for?: Voice Voice TTY Fax
* Email Address:
Emergency Contact:	First and Last Name: Telephone Number (include area code):

Please provide the following information:

Date of Birth:	(mm/dd/yyyy)
Disability:
Additional Disability(ies):
Income Source(s):	SSI SSDI Workers Compensation General Assistance Job Other Support

Please respond to the following:

Are you currently an Ohlone College student?:	Yes No
Are you a Vocational Rehabilitation Client?:	Yes No
Name of your VR Counselor:
Telephone Number of your VR Counselor:	(Include area code and extension.)
Do you have a driver's license?:	Yes No
If yes, do you have a car?:	Yes No

Education

High School

High School Name:
Dates Attended:
Graduated:	Yes No GED

College

College Name:
Dates Attended:
Graduated:	Yes No

Trade School

Trade School Name:
City and State:
Program Name:
Dates Attended:
Certificate:	Yes No

Workability Services

What jobs are you interested in?:
When are you available to work?:	Full time Part time Hours Available:
What service are you interested in?:	Career Counseling Job Training Classes Job Preparation/Placement Followup Services

Work History

Current or Last Employer

Employer Name:
Street Address:	Street Address line 2:
Telephone Number:	(Include area code.)
Start Date:	(mm/dd/yyyy)
End Date:	(mm/dd/yyyy)
Pay:	per	Hour Day Week Month Year
Title and Duties:
Reason for Leaving:

Previous Employer

Employer Name:
Address:	Street Address line 2:
Telephone Number:	(Include area code.)
Start Date:	(mm/dd/yyyy)
End Date:	(mm/dd/yyyy)
Pay:	per	Hour Day Week Month Year
Title and Duties:
Reason for Leaving:

Policy for Services

You must read and agree to the following policies:

Clients agree to be the primary seekers for their own jobs. Workability III will help you find a job, but it is up to the client to follow through on responsibilities. Failure to show up on time will result in a delay of services.
Clients receiving services through Workability III, the student Placement Testing Center, or the Center are subject to Standards of Student Conduct and all Ohlone College regulations.
When looking for jobs, make sure you meet the minimum requirements for the position, and can work the days listed, and that you have transportation to the worksite.
Clients must notify the Workability III office if you get a job, need any assistance, or expect to leave a job or be fired for and reason.

By entering my name below and submitting this form, I certify that I understand and accept the above agreements. I give Ohlone college and/or Workability III Job Placement permission to Fax or Mail my resume to prospective employers. I understand that the staff of Ohlone College WorkAbility III have superivisory responsibility over me in the workplace and will be sharing my personal information with employers. I will abide by following the agreement as set above.

Student Full Name:

Date:

I understand by filling out this form online and submitting it that the agreement is binding.

Your privacy is important to us. Your personal information will not be sold or shared with unaffiliated third parties except as necessary to maintain and process client accounts or when the law requires it.

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