PEP Jobs Client Application
Required fields are marked by *
General Information:
Name:
*
(Required field)
Primary Phone
*
Street Address:
*
(Required field)
Secondary Phone
*
City:
*
State:
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code
*
Email Address
Gender
*
(Required field)
Male
Female
Transgender
Decline to state
Race/Ethnicity:
*
(Required field)
Caucasian
Black
Hispanic
American Indian/Eskimo
Asian
Pacific Islander
Middle Eastern/Arabic
Indian Subcontinent
Unknown
Other
Are you over 18 years old?
*
Yes
No
How did you hear about PEP jobs?
*
(Required field)
Family/friends
DOR
Website
Epilepsy Foundation
Doctor
Returning Client
Event
Other
(specify)
Do you have a DOR counselor?
*
Yes
No
Don't Know
If yes, please list his/her name and office?
(Required field)
Disability Information:
Have you ever been diagnosed with epilepsy?
*
Yes
No
Have you ever been diagnosed with a brain injury (ABI or TBI)?
*
Yes
No
Primary Disability
Select
Auditory- Deaf or Hard of Hearing
Autoimmune disorder: Aids, HIV, Lupus
Chronic Health condition: Diabetes, High Blood Pressure, etc.
Cognitive: Developmental Disability, Learning Disability, Autism/Asperger's, etc.
Mental Health: PTSD, ADD, ADHD, Depression, etc.
Neurological-Epilepsy
Neurological-ABI Acquired Brain injury
Neurological-TBI Traumatic Brain injury
Neurological-Other: Multiple Sclerosis, Encephalitis, Cerebral Palsy, Neuropathy, Memory Loss, Anxiety etc.
Physical-Mobility: Paralysis, Balance, Musculoskeletal, Cancer, etc.
Substance Abuse
Schizoaffective Disorder
Vision- Blind or Low Vision
Other
Secondary Disability
Select
Auditory- Deaf or Hard of Hearing
Autoimmune disorder: Aids, HIV, Lupus
Chronic Health condition: Diabetes, High Blood Pressure, etc.
Cognitive: Developmental Disability, Learning Disability, Autism/Asperger's, etc.
Mental Health: PTSD, ADD, ADHD, Depression, etc.
Neurological-Epilepsy
Neurological-ABI Acquired Brain injury
Neurological-TBI Traumatic Brain injury
Neurological-Other: Multiple Sclerosis, Encephalitis, Cerebral Palsy, Neuropathy, Memory Loss, Anxiety etc.
Physical-Mobility: Paralysis, Balance, Musculoskeletal, Cancer, etc.
Substance Abuse
Schizoaffective Disorder, Spasmadic condition
Vision- Blind or Low Vision
Other
Employment Information:
Are you currently employed?
*
Yes
No
Income sources (check all that apply)
*
(Required field)
SSI
SSDI
Unemployment insurance
Workers comp
State disability
General assistance
Military
Other
(specify)
*Income level does not affect eligibility
Current Income or benefit amount:
*
(Required field)
$
per
Hour
Month
Year
What type of Employment Assistance would you like from PEP Jobs?
*
(Required field)
Resume/Cover letter
Interview skills
Connecting with employers
Other
Job Industry:
*
Job Title:
*
Desired Pay:
*
$
per
Hour
Week
Month
Year
Desired hours per week:
*
How much time do you plan to spend on career search each week?
*
*Indicate number of hours a week
When do you expect to find employment?
*
1 Month
3 Months
6 Months
Other
(specify)
Emergency Information:
Who should be contacted in case of emergency?
*
Relation:
*
Phone:
*
Cell Phone:
Do you have a preferred hospital in case of an emergency?
*
Yes
No
Hospital Name:
Location:
