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 GoalsWe 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 Drag & Drop Files, Choose Files to Upload Upload NYS Driver's/Non Driver's License * 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 CodePrimary 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 SaharaYemenZambiaZimbabweÃ…land 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? *YesNo Trade Layout you What 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. Submit