Job Search Worksheet

2. Name

3. Next Appointment with Career Coach
   Next Appointment with Career Coach

   Next Appointment with Career Coach

5. Number of Job Contacts Assigned

6. Date Job Contacts Are to Be Completed by
   Date Job Contacts Are to Be Completed by

8. Appointment Address

10. City

11. State

12. Zip

14. SNAP E&T Agreement

    If I am a customer of the Supplemental Nutrition Assistance Program Employment and Training (SNAP E&T) Program, I will receive no further notice of this appointment and understand that failure to attend or call to reschedule will result in a penalty request against my SNAP benefits.

    1. I understand.
16. Career Coach

17. Telephone Number

19. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that: your application will not be signed in the sense of a traditional paper document, by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, you may still be required to provide a traditional signature at a later date.

    1. I agree
21. Signature*

    (Customer)

22. Date*
    Date

26. Position 1

28. Company Name

30. Address

32. City

33. State

34. Zip

36. Position Applied For

38. Person Seen

39. Telephone Number

41. Results

42. Date
    Date

46. Position 2

48. Company Name

50. Address

52. City

53. State

54. Zip

56. Position Applied For

58. Person Seen

59. Telephone Number

61. Results

62. Date
    Date

66. Position 3

68. Company Name

70. Address

72. City

73. State

74. Zip

76. Position Applied For

78. Person Seen

79. Telephone Number

81. Results

82. Date
    Date

86. Position 4

88. Company Name

90. Address

92. City

93. State

94. Zip

96. Position Applied For

98. Person Seen

99. Telephone Number

101. Results

102. Date
     Date

106. Position 5

108. Company Name

110. Address

112. City

113. State

114. Zip

116. Position Applied For

118. Person Seen

119. Telephone Number

121. Results

122. Date
     Date

126. Position 6

128. Company Name

130. Address

132. City

133. State

134. Zip

136. Position Applied For

138. Person Seen

139. Telephone Number

141. Results

142. Date
     Date

146. Position 7

148. Company Name

150. Address

152. City

153. State

154. Zip

156. Position Applied For

158. Person Seen

159. Telephone Number

161. Results

162. Date
     Date

166. Position 8

168. Company Name

170. Address

172. City

173. State

174. Zip

176. Position Applied For

178. Person Seen

179. Telephone Number

181. Results

182. Date
     Date

186. Position 9

188. Company Name

190. Address

192. City

193. State

194. Zip

196. Position Applied For

198. Person Seen

199. Telephone Number

201. Results

202. Date
     Date

204. Equal Opportunity Employer/Program
     Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice).

     Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice).

Leave This Blank:


206. 1. Receive an email copy of this form.
207. Email address

     This field is not part of the form submission.

208. Submit

* indicates a required field