Kentucky Career Center Registration Survey

About You

First Name

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Last Name

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Email Address

Phone Number

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Date of Birth

Month

Day

Year

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Race

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Gender

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What is status of your current employment?

Unemployed

Employed full-time

Employed part-time

Self-employed

Employed but have received notice of a layoff or termination

Temporarily laid off or furloughed

Not currently working or seeking employment

Other

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Which of the following situations applies to you?

Click all boxes that apply

I was laid off/downsized.

I currently receive or I am eligible to receive unemployment insurance benefits.

I have exhausted my unemployment insurance benefits.

I was self-employed and my business closed.

I am the spouse of an active-duty member of the U.S. Armed Forces and lost employment because of a military relocation or permanent change of duty station.

I am the spouse of an active-duty service member and am unemployed, underemployed, or having difficulty obtaining or advancing in employment.

I recently separated or will soon separate from the U.S. Armed Forces.

None of these applies to me.

I am unsure and would like a KCC representative to contact me.

Where You Live

Street Address

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City

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State

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Zip Code

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County

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How were you referred?

Goodwill

Power of Work

RISE

SPOT

Other

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