☐ ☐ Paid Unpaid Employer/Organization Address Number Street State Zip Dates Start Date End Date Supervisor Job Title and Duties Contact Number ☐ ☐ Paid Unpaid Have you received/are you receiving job coach services during work experience? ☐ ☐ Yes No If yes, what percent of the time is the job coach involved in the work experience? ☐ ☐ Have you been fired from a job? Yes No If yes, please explain below ☐ ☐ Have you ever quit a job? Yes No If yes, please explain below After the Project SEARCH program is completed, do you plan on getting and maintaining a: ☐ ☐ How many days or hours per week? Full time job Part time job? What kind of work would you like to do? ☐ ☐ Where do you plan on living? ☐ Other/on my own Home Friends TRANSPORTATION: How do you plan to get to Project SEARCH? ☐ ☐ ☐ Metro Access Parents Drive Myself ☐
☐ Paid ☐ Unpaid Employer/Organization Address Number Street State Zip Dates Job Title and Duties Start Date End Date Supervisor Contact Number ☐ Paid ☐ Unpaid Have you received/are you receiving job coach services during work experience? ☐ Yes ☐ No If yes, what percent of the time is the job coach involved in the work experience? Have you been fired from a job? ☐ Yes ☐ No If yes, please explain below Have you ever quit a job? ☐ Yes ☐ No If yes, please explain below After the Project SEARCH program is completed, do you plan on getting and maintaining a: ☐ Full time job ☐ Part time job? How many days or hours per week? What kind of work would you like to do? Where do you plan on living? ☐ Home ☐ Friends ☐ Other/on my own TRANSPORTATION: How do you plan to get to Project SEARCH? ☐ Metro ☐ Access ☐ Parents ☐ Drive Myself
ps-application-2019-2020-final.docx