NFJP Pre-Screening

Please fill out this form to help us determine if you are eligible for the National Farmworker Jobs Program. Contact us if you have any questions or need help completing this form.

Name*
First Middle Last Suffix
Have you earned wages from doing any farm/ranch work in the past two years?*
- Yes
- No
Because you have chosen yes to the above question you must complete the "Employment History Form," located as an option under "Forms" on this website after filling out this form.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Phone Number*
Date of Birth*
MM slash DD slash YYYY
Email Address*
Race (Optional)
Hispanic/Latino?
- Yes
- No
Current Employment Status*
- Employed
- Employed but Rec'd Notice of Termination or Military Separation
- Not in the Labor Force
- Unemployed
Name of Current Employer
Males Over 18: Registered with Selective Service*
- Yes
- No
US Citizen*
- Yes
- No
High School Diploma*
- Yes
- No
Highest Grade Completed*
Date Obtained/Will Be Obtained*
MM slash DD slash YYYY
Name of High School
Location of High School
City State / Province / Region Country
Future Postsecondary Student*
- Yes
- No
Length of Postsecondary Program
- Less that 1 year
- 1 year
- 18 months
- 2 years
- Other
Course of Study
Name of Postsecondary School
Location of Postsecondary School
City State / Province / Region Country
Anticipated Graduation Date
MM slash DD slash YYYY
Student Marital Status*
- Single
- Married
- Divorced
- Separated
- Widowed
Do you have children?*
- Yes
- No
How many children?*
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Emergency Contact Email Address
Notes/Comments

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Black Hills Special Services Cooperative

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