I'm Hired!

Your First Name:

Your Last Name:

Your New Title:

Your Home Phone:

Your E-mail:

MOSES ID Number:

 _______________________________________________________

Company Name:

Company Street Address:

Company City:

Company State:

Zip/Postal Code:

________________________________________________________

Date You Began Work:    

Number of hours/week: 

Choose one that applies:

Full-time Part-TimePermanentTemporary

What’s your pay rate?

Choose one: Per Hour Per Week Per Year

What benefits do you get?

________________________________________________________

How did you learn about this job?  Choose One Job Fair Career Center Networking Newspaper Online Job Search Other

You obtained this employment after Choose One Career Center Services Rapid Responce Services Job Search Workshop Training One-on-one Assistance

What would be the best time to contact you if we need additional information? Choose one:

Morning
Afternoon
Evening

What would be the best way to contact you?

Phone
Mail
Email