(845) 249-4634 Monday - Friday 8:30 am to 4:30 pm

Dutchess County Career Center Customer Registration Form

Auxiliary aids and services are available upon request to individuals with disabilities. Once you complete and submit the form you will receive an email copy for your records.

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Customer Data

Last Name

First Name

Middle Initial

Date of Birth

Gender

Street Address

City/Town

State

Zip Code

County

Home Phone

Cell Phone

How do you prefer to be contacted?

Are you a US Citizen?

Yes

If no, are you authorized to work in the US?

Yes

If yes, Alien Registration Number

Ethnicity/Race

Note: The Ethnicity and Race questions are voluntary. Information is confidential and will only be used for record keeping and affirmative action requirements. You will not be penalized if you do not want to answer.

Ethnicity Race

(Check all that apply)

Hispanic or Latino

Not Hispanic or Latino

White

Black or African American

American Indian or Alaska Native

Asian Native, Hawaiian or Other Pacific Islander

Military

Veterans and "eligible spouses" receive priority of service.

Did you serve in the United States Armed Forces?

Yes

Are you an eligible spouse of a veteran?

Yes

If "Yes" what US military branch?

Dates of Active Service From

Dates of Active Service To

If you're a male born after Dec 31, 1959, are you registered with the US Military Selective Service?

Yes

Employment

Are you currently employed?

Yes

If No, how many weeks have you been out of work?

If Yes, are you employed

Full time

Part time

How many hours do you work per week?

Employment Objective

Employment objective/Type of work you are seeking

Job Title

List most recent occupation(s)/job(s)

Job Title

Experience in this Job: Years

Experience in this Job: Months

Job Title

Experience in this Job: Years

Experience in this Job: Months

Acceptable Job Locations

I am willing to work within the following zip code, county or state (check the number of miles and write the zip code)

Number of Miles

100

from...

Zip Code Location

County Location

State Location

Work History

Most recent job held first

Job Title

Employer

Job Address

Job City

Job State

Job Type

Start Date

End Date

Supervisor

Supervisor Phone Number

Wage $

Paid

Hours per Week

Reason for Leaving

Job Duties

Additional Work History

Next most recent job held

Job Title

Employer

Job Address

Job City

Job State

Job Type

Start Date

End Date

Supervisor

Supervisor Phone Number

Wage $

Paid

Hours per Week

Reason for Leaving

Job Duties

Driver's License

Do you have a driver's license?

Yes

Issuing State

What type of license do you have?

Endorsements

Do you need public transportation to get to a job?

Yes

Do you have reliable transportation to and from work?

Yes

Certificates/Licenses

Do you have an occupational certificate or license?

Yes

Certificate/License

Issuing organization or locality

Issue date (month/year)

Licensing State

Licensing Country

Additional Certificate or License

Do you have an occupational certificate or license?

Yes

Certificate/License

Issuing organization or locality

Issue date (month/year)

Licensing State

Licensing Country

Additional Certificate or License

Do you have an occupational certificate or license?

Yes

Certificate/License

Issuing organization or locality

Issue date (month/year)

Licensing State

Licensing Country

Schools

Do you have a college degree, diploma or educational certificate?

Yes

Course of study

Degree

Date completed

Issuing institution

Institution's State

Institution's Country

Course of study

Degree

Date completed

Issuing institution

Institution's State

Institution's Country

Job Skills and Qualifications

List at least one.
Include skills and abilities that you used in your job(s), volunteer work, personal experiences, or that you have acquired through school or training. Examples: laboratory techniques, carpentry, welding, ability to read blueprints, typing, and computer skills such as word processing software, programming languages, or computer assisted design. Also, include languages in which you are fluent.

List any honors you have received or outside activities you participate in

I certify that the information given on this document is true and accurate to the best of my knowledge.

Signature

Today's Date

Dutchess One Stop Career Center
191 Main Street, Poughkeepsie, NY 12601

Driving Directions
We are co-located with the
NYS Department of Labor

Hours of Operation
Monday-Friday 8:30am-5:00pm
Resource Room
Monday - Friday 9:00am-4:00pm

Phone (845) 249-4634 | Email Us

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