SER Client Registration Form
Date :
Name:
Mail Address
Reside
in Fairfax County
Do
not reside in Fairfax County
Phone
Alternate Phone :
Birth Date:
Email Address:
Married Single
Male
Female
How did you learn about
SER?
Work Permit Status:
Your Country of Origin:
US
Citizen Not US Citizen
Have
Green Card Do Not Have Green Card Not
Applicable
Have
Working Visa Do Not Have Working Visa Not
Applicable
Speak
Spanish Do Not Speak Spanish
Handicaps:
Do
not have any physical limitations Have physical limitations
Physical
limitations do not affect job choice Physical limitations affect job choice
Education:
Highest year of education completed:
College Degree 1 / Dates / Major :
College Degree 2 / Dates / Major:
Graduate Degree 1 / Dates / Major :
Graduate Degree 2 / Dates / Major:
Licenses:
Job Status:
Career
Military Retired Not Career Military Retired
US
Military Veteran Not US Military Veteran
US Government Retired Not
US Government Retired
Date :
Security Clearance:
Have
Active Clearance Do Not Have Active Clearance
Have
Past Clearance Do Not Have Past Clearance
Date :
Office Skills:
Words Typed Per Minute :
Do
not take shorthand Take shorthand
Do
not use computer Use computer
Software used
Work Peferences: Willing to work:
Full time
Part
time
Evenings
Nights
Weekends
Lowest Acceptable Salary:
Yearly:
Hourly:
Do you need health benefits:
No Yes
List the geographic area(s) in the metropolitan
area where you will work:
Do you have a driver's license?
No
Yes
Do you have a car? No
Yes
Experience: If you don't have
a résumé, please complete this experience block. List most
recent employment first:
Title of position :
Employment dates:
Company name and city:
Describe briefly major elements
of your job:
Title of position:
Employment dates:
Company name and city:
Describe briefly major elements
of your job:
List jobs that you are willing to have and
feel qualified to do. This is very important!
1:
2:
3:
List hobbies, skills, personal interests
or volunteer experience that you feel would help you in your job search:
Areas in which you would like assistance:
Résumé
development or revision
Job
interviewing techniques
Job
search techniques
Language
assistance, ESL, etc.
Other
job skills
Racial/ethnic origin — Please
check one:
White
not Hispanic
Black
not Hispanic
Hispanic
American
Indian or Alaskan Native
Asian
Middle
Eastern
Other
FAIRFAX
COUNTY RESIDENTS ONLY Income Category —
Check one, if applicable for Household Size
