SER Farmworkers Application SER Farmworkers Program Application Name(Required) First Last How did you hear about us?(Required) Date MM slash DD slash YYYY Address(Required) Street Address City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Employment Type(Required) Seasonal Farmworker Migrant Farmworker Applicant Status(Required) Adult Youth Gender(Required) Male Female Age(Required) Date of Birth(Required) MM slash DD slash YYYY Number of people living in residence(Required) Total Income(Required)Income(Required) Annual Monthly Foster Child?(Required) Yes No Ex-Offender?(Required) Yes No Veteran/Spouse of Veteran?(Required) Yes No Disability?(Required) Yes No Homeless?(Required) Yes No Public Assistance (Select all received)(Required) SNAP TANF SSI State/Local Public Assistance Receives Free/Reduced Price Foster Child Payments Child Support Refugee Cash Assistance Unemployment Insurance None Other If you selected "Other", please tell us which program: Are you a farmworker or have you worked on a farm within the past 24 months?(Required) Yes No Are you a dependent of a farmworker?(Required) Yes No Have you or anyone in your family worked on a farm or in food processing in the last 2 years?(Required) Yes No How long did you (or your family member) work there?(Required) What were your job duties?(Required) How long did you work there?(Required) Did you have other employment where you were paid in cash?(Required) Yes No Are you a single parent with sole custody of your child(ren)?(Required) Yes No In the last two years, did you ever travel to work on a farm? If so, in which state(s)?(Required) Have you moved or traveled and stayed away from your home to work?(Required) Yes No Mode of transportation:(Required) Car Bus Family/Friend Other What distance are you willing to travel for training?(Required) Highest grade you completed:(Required) High School Diploma GED Other If you selected "Other", please specify: Can you read/write/speak English at a functional level?(Required) Yes No List job training interests:(Required) Is there anything that affects the type of work you are able to do?(Required) Yes No If you selected "Yes" please provide us more information: 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. YesSignature(Required) Date MM slash DD slash YYYY
