2. Full Name
4. Career Specialist Name
5. Career Specialist Phone #
7. I must complete the following job search contacts and turn in this form at my next appointment as proof of my job search efforts.
9. Minimum # of Contacts
10. Timeframe for Contacts
    Timeframe for Contacts Start Date

    —

    Timeframe for Contacts End Date

    Before next appointment

11. Next Appointment
    Next Appointment

    Next Appointment
13. Position #1
15. Date
    Date
17. Company Name
18. Company Address
20. City
21. State
22. Zip Code
24. Company Website

    If contacted/applied online

25. Company Phone Number
27. Job Title/Position
28. Person Spoken To:

    1. Online (no contact)
    2. Spoke with a Person
29. Name of Person:

    Leave blank if done online

31. What did you do?

    1. Application
    2. Interview
    3. Testing
    4. Employer Contact
32. How did you do it?

    1. In-person
    2. Fax/Email
    3. Online
    4. Phone
33. Where was it done?

    1. Workforce Center
    2. Library
    3. Worksite
    4. Home
    5. Cell Phone
37. Position #2
39. Date
    Date
41. Company Name
42. Company Address
44. City
45. State
46. Zip Code
48. Company Website

    If contacted/applied online

49. Company Phone Number
51. Job Title/Position
52. Person Spoken To:

    1. Online (no contact)
    2. Spoke with a Person
53. Name of Person:

    Leave blank if done online

55. What did you do?

    1. Application
    2. Interview
    3. Testing
    4. Employer Contact
56. How did you do it?

    1. In-person
    2. Fax/Email
    3. Online
    4. Phone
57. Where was it done?

    1. Workforce Center
    2. Library
    3. Worksite
    4. Home
    5. Cell Phone
61. Position #3
63. Date
    Date
65. Company Name
66. Company Address
68. City
69. State
70. Zip Code
72. Company Website

    If contacted/applied online

73. Company Phone Number
75. Job Title/Position
76. Person Spoken To:

    1. Online (no contact)
    2. Spoke with a Person
77. Name of Person:

    Leave blank if done online

79. What did you do?

    1. Application
    2. Interview
    3. Testing
    4. Employer Contact
80. How did you do it?

    1. In-person
    2. Fax/Email
    3. Online
    4. Phone
81. Where was it done?

    1. Workforce Center
    2. Library
    3. Worksite
    4. Home
    5. Cell Phone
85. Position #4
87. Date
    Date
89. Company Name
90. Company Address
92. City
93. State
94. Zip Code
96. Company Website

    If contacted/applied online

97. Company Phone Number
99. Job Title/Position
100. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
101. Name of Person:

     Leave blank if done online

103. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
104. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
105. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
109. Position #5
111. Date
     Date
113. Company Name
114. Company Address
116. City
117. State
118. Zip Code
120. Company Website

     If contacted/applied online

121. Company Phone Number
123. Job Title/Position
124. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
125. Name of Person:

     Leave blank if done online

127. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
128. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
129. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
133. Position #6
135. Date
     Date
137. Company Name
138. Company Address
140. City
141. State
142. Zip Code
144. Company Website

     If contacted/applied online

145. Company Phone Number
147. Job Title/Position
148. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
149. Name of Person:

     Leave blank if done online

151. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
152. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
153. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
157. Position #7
159. Date
     Date
161. Company Name
162. Company Address
164. City
165. State
166. Zip Code
168. Company Website

     If contacted/applied online

169. Company Phone Number
171. Job Title/Position
172. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
173. Name of Person:

     Leave blank if done online

175. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
176. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
177. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
181. Position #8
183. Date
     Date
185. Company Name
186. Company Address
188. City
189. State
190. Zip Code
192. Company Website

     If contacted/applied online

193. Company Phone Number
195. Job Title/Position
196. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
197. Name of Person:

     Leave blank if done online

199. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
200. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
201. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
205. Position #9
207. Date
     Date
209. Company Name
210. Company Address
212. City
213. State
214. Zip Code
216. Company Website

     If contacted/applied online

217. Company Phone Number
219. Job Title/Position
220. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
221. Name of Person:

     Leave blank if done online

223. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
224. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
225. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
229. Position #10
231. Date
     Date
233. Company Name
234. Company Address
236. City
237. State
238. Zip Code
240. Company Website

     If contacted/applied online

241. Company Phone Number
243. Job Title/Position
244. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
245. Name of Person:

     Leave blank if done online

247. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
248. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
249. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
253. Position #11
255. Date
     Date
257. Company Name
258. Company Address
260. City
261. State
262. Zip Code
264. Company Website

     If contacted/applied online

265. Company Phone Number
267. Job Title/Position
268. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
269. Name of Person:

     Leave blank if done online

271. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
272. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
273. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
277. Position #12
279. Date
     Date
281. Company Name
282. Company Address
284. City
285. State
286. Zip Code
288. Company Website

     If contacted/applied online

289. Company Phone Number
291. Job Title/Position
292. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
293. Name of Person:

     Leave blank if done online

295. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
296. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
297. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
301. Position #13
303. Date
     Date
305. Company Name
306. Company Address
308. City
309. State
310. Zip Code
312. Company Website

     If contacted/applied online

313. Company Phone Number
315. Job Title/Position
316. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
317. Name of Person:

     Leave blank if done online

319. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
320. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
321. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
325. Position #14
327. Date
     Date
329. Company Name
330. Company Address
332. City
333. State
334. Zip Code
336. Company Website

     If contacted/applied online

337. Company Phone Number
339. Job Title/Position
340. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
341. Name of Person:

     Leave blank if done online

343. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
344. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
345. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
349. Position #15
351. Date
     Date
353. Company Name
354. Company Address
356. City
357. State
358. Zip Code
360. Company Website

     If contacted/applied online

361. Company Phone Number
363. Job Title/Position
364. Person Spoken To:

     1. Online (no contact)
     2. Spoke with a Person
365. Name of Person:

     Leave blank if done online

367. What did you do?

     1. Application
     2. Interview
     3. Testing
     4. Employer Contact
368. How did you do it?

     1. In-person
     2. Fax/Email
     3. Online
     4. Phone
369. Where was it done?

     1. Workforce Center
     2. Library
     3. Worksite
     4. Home
     5. Cell Phone
373. I understand that to receive credit for job contacts every field for each position must be completed.

     ***I verify that the information provided on this form is true and correct.  Providing false information for the purpose of inappropriately obtaining TANF or SNAP E&T benefits may result in civil, criminal, or administrative penalties***

375. 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
377. Signature
378. Today's Date
     Today's Date
380. Equal Opportunity Employer/Program

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

382. Funding
     Public Information

     These services are funded in whole or in part with federal funds. More detailed information is located on the Board’s website.

Leave This Blank:


384. 1. Receive an email copy of this form.
385. Email address

     This field is not part of the form submission.

386. Submit

* indicates a required field