Kentucky Career Center Registration Survey

About You

First name

Last name

Email address (optional)

Phone number

Date of birth

Race

Gender

What is status of your current employment?EmployedTerminatedLaid offQuitCompany Shut DownOther

Which of the following situations applies to you?

Select all that apply.

I was laid off/downsized.I currently receive or I am eligible to receive unemployment insurance benefits.I have exhausted my unemployment insurance benefits.I was self-employed and my business closed.I am the spouse of an active-duty member of the U.S. Armed Forces and lost employment because of a military relocation or permanent change of duty station.I am the spouse of an active-duty service member and am unemployed, underemployed, or having difficulty obtaining or advancing in employment.I recently separated or will soon separate from the U.S. Armed Forces.None of these applies to me.I am unsure and would like a Kentucky Career Center representative to contact me.

Where You Live

Street address

City

State

ZIP code

County

How you found us

How did you hear about us? (optional)

If you were referred to us by another program or partner, please list them here. (optional)

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