ࡱ> WYV#` UBbjbj5G5G zIW-W-G H H H 8 D t+D!V"V"V"V"V"P##H*******$,h/+E8'V"V"8'8'+V"V"U+^(^(^(8'RV"V"*^(8'*^(^(^(V"8! ?Z|H '^((k+0+^(/ (/^(/v(`$$$h^(%Tr%$$$$$$++ (R$$$$$$+8'8'8'8' U+ State of Iowa Promise Jobs  Work Experience Placement Program Participant Data Form Personal Data:  FORMTEXT       FORMTEXT      Last Name First Name Middle InitialSocial Security Number  FORMTEXT       FORMTEXT      Street Address City State Zip CodeArea Code and Telephone Number Work Experience Data: Program Referral  FORMCHECKBOX WEP  FORMCHECKBOX JTPA Department: FORMTEXT      Division: FORMTEXT       Supervisor Name: FORMTEXT      Phone: FORMTEXT       Date Started: FORMTEXT      Work Location: FORMTEXT      County: FORMTEXT       IMPORTANT: This form will not be accepted unless signed by your program counselor. The signatures below certify that you are enrolled in a state administered program that provides training and work experience. After completing three months of satisfactory job performance, you are eligible to submit an application for employment and be placed on promotional eligible lists for job classes for which you are qualified. (If you are applying for job classes which require typing you will be required to successfully pass the keyboard test prior to your name being placed on the eligible lists.) Program Counselor Signature Date Participant Signature Date EEO and AA Data Survey Iowa State Government is committed to the principles of Equal Employment Opportunity and Affirmative Action. To evaluate the success of our EEO and AA programs, we must collect information about job applicants. Please share some information about yourself to assist us in doing this. This information is voluntary and is used only for program evaluations and reporting requirements. Please write your numbered responses to items A through D in the corresponding boxes. ABCC FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  A. B.What sex are you? 0. Male 1. Female What is your age? 0. 18 or younger 1. 19-29 2. 30-39 3. 40-49 4. 50-59 5. 60-69 6. 70 or overC. D.Of which racial/ethnic group do you consider yourself a member? 0. White 3. Native American or 1. 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Asian or Pacific 4. Latino Islander 5. Decline to Respond Do you have a disability that is a physical or mental impairment that substantially limits one or more major life activities; do you have a record of such an impairment; or are you regarded as having such an impairment? 0. No 1. Yes 2. 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