SER Farmworkers Application

SER Farmworkers Program Application

Name(Required)
MM slash DD slash YYYY
Address(Required)
Employment Type(Required)
Applicant Status(Required)
Gender(Required)
MM slash DD slash YYYY
Income(Required)
Foster Child?(Required)
Ex-Offender?(Required)
Veteran/Spouse of Veteran?(Required)
Disability?(Required)
Homeless?(Required)
Public Assistance (Select all received)(Required)
Are you a farmworker or have you worked on a farm within the past 24 months?(Required)
Are you a dependent of a farmworker?(Required)
Have you or anyone in your family worked on a farm or in food processing in the last 2 years?(Required)
Did you have other employment where you were paid in cash?(Required)
Are you a single parent with sole custody of your child(ren)?(Required)
Have you moved or traveled and stayed away from your home to work?(Required)
Mode of transportation:(Required)
Highest grade you completed:(Required)
Can you read/write/speak English at a functional level?(Required)
Is there anything that affects the type of work you are able to do?(Required)
The information I have provided is true to the best of my knowledge. I am aware that the information I have provided is subject to review and verification.
MM slash DD slash YYYY