Job Placement Application

This form should take about 10-20 minutes to fill out.

Please reach out to [email protected] If you have additional questions about this form.

3 Easy Sections

Personal & Background Information
- a few questions to help us get to know you better.
Commitment Letter
- a promise you sign to show you're ready to work with us to find a job.
Release of Information
- gives us permission to share your story to help you get hired.

Your responses will help us provide the most relevant job placement, and career opportunities tailored to your unique journey. Please answer honestly and thoroughly—your future starts here.

Message types may include: promotional offers, appointment reminders, account updates, and customer service notifications.
Message frequency varies based on your activity and preferences.
You may receive up to [10] messages per week.
Standard message and data rates may apply. Check with your mobile carrier for details about your messaging plan.
You can opt-out at any time by texting STOP to (385) 452-8680.
Your data or phone numbers will not be shared or sold to third parties
After you send the message "STOP" to us, we will send you a reply message to confirm that you have been unsubscribed. You will no longer receive messages from us.
For help, text HELP to (385) 452-8680 or contact us at [email protected].
Questions? Contact us at:
Email: [[email protected]]
Phone: [(385) 452-8680]

Section 1: Personal & Background Information

First Name *

First Name & Middle Initial

Last Name *

Email *

Phone *

Is this your personal contact information? *

if not please list who's

By checking the box I agree to receive text messages from The Second Chance Hub at the mobile number By checking the box I agree to receive text messages from The Second Chance Hub at the mobile number provided (385) 452-8680. I understand that message frequency may vary and that message and data rates may apply. I can opt-out at any time by replying STOP. Reply HELP for help. (385) 452-8680. I understand that message frequency may vary and that message and data rates may apply. I can opt-out at any time by replying STOP. Reply HELP for help.

Terms

By checking the box above, you agree to our Privacy Policy and Terms of Service (linked below).

What city are you located in *

Birthdate *

MM-DD-YYYY

How were you referred? *

How did you hear about us?

What is your highest level of education? *

If you could rank your top 3 career choices what would they be?

1.
2.
3.

Any entry level jobs you would completely avoid? *

Your most recent jobs

If a formal background check is conducted what would the results be? *

short description of formal charges on your record with dates

Are you willing to work graveyard shifts? *

Yes

Would you be willing to work Saturdays and Sundays? *

Yes

Do you have a vehicle? *

Yes

Do you have a Drivers License? *

Yes

If no, please explain what steps you need to accomplish to recieve your Drivers License

Any other important skills you would like to share with an employer

short description... please list any certificates you may have received or skills you have learned from UCI... For example: I can operate heavy machinery, I know how to weld, I know how to sew, I know how to program a CNC machine, etc.

Government Funding Questions

This will help us understand what services we can help you apply for!

Check what services you have heard of before

Vocation Rehab

Department of Workforce Services

Haven't heard of these programs

This can include if you have previously been on VOC Rehab

Do you have a future appointment with Vocational Rehab or Department of Workforce Services?

Yes

When is your next appointment?

MM-DD-YYYY

Commitment Agreement

I agree to work with Barder Staffing for 3 straight months to help me find a job.

If I find a job on my own, I will contact Barder Staffing before I start working, this way we can keep government programs in place for career strategies.
I will be a responsible job seeker by doing the following
- showing up on time for interviews - 10 min early
- give prompt feedback after interviews
- update resumes for each job application
- respond to emails and texts in a timely manor.
The Second Chance Hub will give me resources and calendars to make appointments. I will be in charge of scheduling appointments on my own.
I give my consent to Barder Staffing to record and share video content for the purpose of creating more interview opportunities.
I understand this work will help me get an entry level job to help me on my future career path.

Commitment Date *

MM-DD-YYYY

Commitment Signature *

Clear

By signing your Full Name in the box above, you consent to the use of your typed name as your electronic signature

Release of Information

I give permission to Barder Staffing to share information about my past with employers who may want to hire me.

This includes talking about:

My criminal record
What happened in my case
What I have done to move forward and change
Why I am ready to work and be a good employee

I understand that this information will only be shared to help me get a job.

I know that I can stop this permission at any time by telling Barder Staffing in writing.

I am signing this form because I want help finding a job and I trust Barder Staffing to use this information the right way.

Release of Information Date *

MM-DD-YYYY

By signing your Full Name in the box above, you consent to the use of your typed name as your electronic signature *

Clear

By signing your Full Name in the box above, you consent to the use of your typed name as your electronic signature