WORK HISTORY/JOB SKILLS

Last: ______________ First:_______________ MI: __ SSN: ____-___-____

Street:_______________________ City:_____________ County:______ Zip:_____

Phone: _____ -______- ______ Birthdate: ____________

Case Manager:______________________ Media of Choice: LP/B

Job Title: _________________________

Employer Name and Address: ________________________________________

Date Started: ___________ Date Left: ___________

mm/dd/yyyy mm/dd/yyyy

Reason for leaving: _____________________________________________________

Duties: __________________________________________________________________

Job Skills: ______________________________________________________________

Weekly Wages: $________

Hours worked per week: _______

Job Title: _________________________

Employer Name and Address: ________________________________________

Date Started: ___________ Date Left: ___________

mm/dd/yyyy mm/dd/yyyy

Reason for leaving: _____________________________________________________

Duties: __________________________________________________________________

Job Skills: ______________________________________________________________

Weekly Wages: $________

Hours worked per week: _______

Job Title: _________________________

Employer Name and Address: ________________________________________

Date Started: ___________ Date Left: ___________

mm/dd/yyyy mm/dd/yyyy

Reason for leaving: _____________________________________________________

Duties: __________________________________________________________________

Job Skills: ______________________________________________________________

Weekly Wages: $________

Hours worked per week: _______

Job Title: _________________________

Employer Name and Address: ________________________________________

Date Started: ___________ Date Left: ___________

mm/dd/yyyy mm/dd/yyyy

Reason for leaving: _____________________________________________________

Duties: __________________________________________________________________

Job Skills: ______________________________________________________________

Weekly Wages: $________

Hours worked per week: _______