Chinatown Service Center
Workforce Development · Intake Form

Welcome

This form helps us get to know you so we can match you with the right job, training, or service. It takes about 8–10 minutes.

  • 1 You can leave any question blank except Name, Date of Birth, Phone, and Signature.
  • 2 Your information is stored privately. Only Workforce staff can see it.
  • 3 If you need help, ask a staff member — they can fill it out for you.

Intake

Personal Information

Required fields marked with *

Demographics

Optional — used for funder reporting in aggregate only.

Race / Ethnicity (check all that apply)

Education

Employment Status

Current Employment Status

Services You Are Interested In

Check all that apply.

Services

Additional Support Needs

We can refer you to partners for these.

Support needs

Emergency Contact

In case we cannot reach you.

Employment History

Most recent first. Up to 3 — leave blank if none.

Most Recent Job

Previous Job

Earlier Job

Certification & Signature

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that providing false information may result in being denied services.

I authorize the Chinatown Service Center to keep this information in my client file and to share it with funders or partner agencies only as required to provide me with services or to comply with grant reporting.

I understand that my participation in any program is voluntary, and that I may withdraw at any time without losing access to other CSC services.

Signature * Sign with your finger, mouse, or stylus.