Register for an appointment with a counselor at the Hicksville or Massapequa Career Centers Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1Personal Information2Ethnicity3Education4Job History and Military5Employment Preferences6Trade Adjustment Assistance7Licenses and Certificates8Skills and Goals9Equal Opportunity10Job Matching SkillsWe must collect personal information from customers to comply with federal reporting requirements for Workforce Innovation and Opportunity Act (WIOA) funded programs. The information is for WIOA purposes only. New York State Career Centers follow federal guidelines on handling and the protection of personally identifiable information. Auxiliary aids and services are available upon request for individuals with disabilities. Is English your preferred language? *YesNoIf other than English, what is your preferred language? *First Name *Last Name *MIDate of Birth *Gender *GenderMaleFemaleNon-BinaryIf you were born after December 31, 1959, are you registered with the US Military Selective Service? *YesNoSocial Security No. or New York Identification Number *NYS Driver's/Non Driver's License ID NumberUpload Social Security Card Front Drag & Drop Files, Choose Files to Upload Upload Social Security Card Back Drag & Drop Files, Choose Files to Upload Upload NYS Driver's/Non Driver's License Front * Drag & Drop Files, Choose Files to Upload Upload NYS Driver's/Non Driver's License Back * Drag & Drop Files, Choose Files to Upload Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Driver's a for Primary Phone *Email *Are you a US Citizen? *YesNoAre you authorized to work in the US? *YesNoWhat is your Alien Registration Number? *NextEthnicity/Race Note: the Ethnicity and Race questions are voluntary. Information is confidential and will only be used for record keeping and affirmative action requirements. You will not be penalized if you do not answer. EthnicityEthnicityHispanic or LatinoNon-Hispanic or LatinoRaceWhiteBlack or African AmericanAmerican Indian or Alaska NativeChineseAsian IndianFilipinoKoreanBangladeshiPakistaniJapaneseVietnameseNepaleseBurmeseThaiOther AsianNative HawaiianGuamanian and ChamorroSamoanOther Pacific IslanderNextEducation Highest Grade Level Completed *None123456789101112DiplomaHS DiplomaHS EquivalencyNo DiplomaIEP Diploma/Disabled with Certification of Attendance/CompletionNote: IEP Diploma/Disabled with Certification disclosure is voluntary. You will not be penalized for nondisclosure of IEP Diploma/Disabled with Certification of Attendance/CompletionAre you attending a secondary, post-secondary, vocational, technical or academic school full time? *YesNoIf you are between terms, do you intend to return to school?YesNoDo you have a college degree, diploma, or educational certificate? *YesNoCourse of Study *Degree *Issuing Institution *Completion Date *StateStateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYCountry Add Remove NextEmployment Are you currently employed? *YesNoFull Time or Part Time *Full Time or Part TimeFull TimePart TimeHow many hours do you work per week? *How many weeks have you been out of work? * Work History Job Title *Employer *AddressAddress Line 1CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryStart Date *End DateHours Worked per WeekSupervisor's NameSupervisor's Contact (Phone/Email)Wage *Wage/Time *Wage EarnedPer HourPer DayPer WeekPer MonthPer YearOtherReason for leaving *Job Duties * Add Additional Work History Remove Military Note: Veterans and “eligible spouses” receive priority of service. Did you serve in the United States Armed Forces? *YesNoAre you an eligible spouse of a veteran? *YesNoWhat US Military Branch? *Begin Date of Service *End Date of ServiceNextEmployment Preferences Check your work preferences. Work Week *Full TimePart TimeDuration *Regular (more than 150 days)Regular or Temporary (4-150 days)Temporary (3 days or fewer)Length of EmploymentMinimum Acceptable Wage *Date you are available for work *Shifts you are willing to work *First (Shift begins in the morning)Second (Shift begins in the afternoon/early evening)Third (Shift that begins at night)SplitRotatingCheck all that apply.Are you a Migrant or Seasonal Farm Worker? *YesNoFor definitions, use the Contact Us form on the website.Acceptable Job Location I am willing to work within the specified miles from specified Zip Code, County, or State. I am willing to work:Miles From: * Employment Objective Job title(s) NextTrade Adjustment Assistance (TAA) Have you been notified by the New York State Department of Labor (received form TA722) that you are eligble for Trade Adjustment Assistance? *YesNoWhat is the TAA Petition Number? *Were you separated from your employment due to foreign trade? *YesNoNextDo you have a Driver's License? *YesNoIssuing State *Issuing StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYWhat type of driver's license do you have? *Class A (tractor trailer)Class B (truck/bus)Class C (light truck commercial)Class Cn (C-non-CDL)Class D (operators)Class E (taxi)Class M (motorcycle)EndorsementsPassenger transportsHazardous materialsTank vehiclesMotorcycleSchool busDoubles/triplesTank hazardAir brakesDo you need public transportation to get to a job? *YesNoDo you have reliable transportation to and from work? *YesNoCertificates/Licenses Do you have an occupational certificate or license? *YesNoCertificate/License *Issuing Organization/Locality *Issue Date *Issue State *Issuing StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYIssuing Country *NextJob Skills and Qualifications Include skills and abilities that you used in your job(s), volunteer work, personal experiences, or that you have acquired through school or training. Examples: laboratory techniques, carpentry, welding, ability to read blueprints, typing, and computer skills such as word processing software, programming languages, or computer assisted design. Also, include languages in which you are fluent. Skills/Qualifications * Add Remove List qualities or accomplishments related to your employment goal * List any honors you have received or outside activities you participate in * I certify that the information given on this document is true and acurate to the best of my knowledge. NextParagraph TextEqual Opportunity is THE LAW. It is against the law for the New York State Department of Labor (NYSDOL) as a recipient of Federal financial assistance to discriminate on the following basis: Against any individual in the United States on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief, and against any beneficiary or programs financially assisted under Title I of the Workforce Innovation and Opportunity Act of 2014 (WIOA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WlOA Title I financially assisted program or activity. The recipient must not discriminate in any of the following areas: Deciding who will be admitted, or have access, to any WlOA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to such a program or activity; or making employment decision in the administration of, or in connection with such a program or activity. What to do if you believe you have experienced discrimination. If you think you have been subjected to discrimination under a WlOA Title 1-firiancially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: Omoye Cooper Director Division of Equal Opportunity Development New York State Department of Labor State office Campus Building 12, Room 540, Albany, New York, 12240 usaarui@labor.state.ny.us Phone: (518) 457-1984 (‘I’DD) 1-800-662-1220 (VOICE) 1-800-421-1220; or you may file a complaint directly with: Director, Civil Rights Center (CRC) U.S. Department of Labor 200 Constitution Avenue, NW, Room N-4123, Washington,. D.C. 20210 Local Workforce Investment Area Equal Opportunity Officer: Catherine Frisone The Workforce Partnership 977 Hicksville Road Massapequa, New York 11758 cfrisone;@oysterbav-ny.gov Phone: (516) 797-7922 Fax: (516) 797-4565 If you file your complainy with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center, (see address above). If the recipient does not give you a written Notice of Final Action within 90 days if the day on which you filed your complaint, you do not have to wait for tehe recipient to issue that Notice before filing a complaint with the CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed the complaint with the recipient). If the recipient does not give you written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with the CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. You have the right to file a complaint regarding the implementation of any Title I financially assisted program or activity if you think you have been discriminated against. The Grievance Officer, Ms. Catherine Frisone, will be available to review all complaints, assist in their processing and provide necessary forms or technicial assistance. Ms. Frisone may be contacted at 977 Hicksville Road, Massapequa, New York, 11758, (516) 797-4560, Fax (516) 797-4565, or by email cfrisone@oysterbay-ny.gov. Non-Criminal and Non-Discrimination Complaints Complaints and Grievances from Participants and other Interested Parties affected by Local Workforce Investment System, including One-Stop Partners and Service Providers. All complaints must be in writing, signed and filed within one year of the facts that gave rise to the complaint. Prior to a formal hearing, the Grievance Officer will attempt to resolve the matter informally or at a conciliation conference. If no resolution is reached, the complainant is entitled to a hearing held on written notice. Such written notice must state date, place, and time of hearing. The complainant may be present at the hearing and may present evidence. The informal resolution and the hearing will be completed within 30 days of the filing of the grievancs or complaint. A written decision must be issued to the complainant within. 60 days of the filing of the complaint and must include notification to the complainant of the right to request a State level review of the findings. State level appeals must be submitted in writing to the State Hearing Offcier within 10 days of receipt of the Local Area findings. In addition, if no decision is rendered at the Local Area level within the prescribed 30-day period, the complainant may, within 15 days after such decision was due, appeal for a State Review. The information should be sent to: New York State Workforce Investment Act Hearing Officer, New York State Department of Labor, State Office Building Campus, Building 12, Room 446, Albany, New York, 12240. The Hearing Officer shall issue a decision within thirty days of receipt of a request for review by a complainant. Criminal Complaints All information and complaints involving fraud, abuse, or other criminal activity shall be reported directly and immediately to the United States Department of Labor, Washington D.C., 20210. At the same time, a copy should be sent to the New York State Department of Labor in the care of the State Representative, 202 West Old Country Road, Hicksville, New York, 11801. If your complaint is not related to the Workforce Innovation and Opportunity Act, it will be referred to the appropriate agency or agencies. Complaints may also involve or entite complainants to recourse from the State or Federal agencies pursuant to applicable laws. Please be assured that the filing of a complaint will NOT result in negative treatment or denial of services to the complainant. I have read and understand the above policy and procedures for filing a complaint. *I have read and understand the above policy and procedures for filing a complaint.NextCertifications/Occupational LicensesAcupunctureAutomated External Defibrillator (AED)AirbrakesAsbestos RemovalAutomotive Service Excellence (ASE)- Auto MechanicsAthletic TrainerAudiologyBarberCredentialed Alcohol and Substance Abuse Counselor (CASAC)Certified First ResponderChiropractorCertified Nursing Assistant (CNA)CosmetologyCertified Public Accountant (CPA)Dental AssistantDental HygienistDialysis NurseDiesel MechanicDietician-NutritionistDoubles/Triples EndorsementDriver’s License ClassCommercial Driver’s License (CDL)ElectricianEmergency Medical Technician (EMT)Fire TechnologyForklift OperatorHazardous MaterialsHazardous Waste Operations and Emergency Response Standard (Hazwoper)Certified Home Health AideInsurance AdjusterInsurance AgentInsurance BrokerInsurance ConsultantLab TechnicianLand SurveyorMassage TherapyMedical AssistantMidwifeNurse PractitionerNYS CounselorNYS InspectionNYS TeacherOccupational TherapyOccupational Therapy AssistantOpticianOccupational Safety and Health Administration (OSHA)Passenger EndorsementPersonal Care AidePhlebotomyProfessional in Human Resources (PHR)Physical TherapyPhysical Therapy AssistantPhysician AssistantPilot’s LicensePlumberRadiologyReal EstateRegistered Nurse (RN)SecuritySocial WorkerSpeech PathologySubmit