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2. Location*

   1. NCWorks Career Center, 1105 South Briggs Avenue
   2. NCWorks Career Center Northgate Mall 1058 W. Club Blvd., Suite 848
3. 
5. First Name*
6. Last Name*
8. Address*
10. City*
11. State*
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
12. Zip Code*
14. Gender*
    -- Select One --MaleFemaleOther
15. Birthdate*
    Birthdate
17. Purpose of Visit*
    -- Select One --Appeals HearingCareer CounselingCareer Resource CenterCenter OrientationJustice Involved Program/Former Offender InitiativeFaxFeatured Employer EventFood and Nutrition ProgramHuman Resources Development WorkshopInterview SimulatorJob CorpsJob Search/ReferralsOtherOlder Workers ProgramPrintRESEA (Reemployment Services and Eligibility Assessment)EAI (Employability Assessment Interview)Resumé reservation for workshopI would like resumé assistance Scheduled AppointmentTAA (Trade Adjustment Act)Tax AuditorUnemployment InsuranceVeteransVoc. RehabWorkshop (General)Workforce Innovation & Opportunity Act (WIOA)Yes Program (Youth Employed and Succeeding)
19. With Who
    -- Select One --Christopher LunsfordDavid AndersonLinzie AtkinsGarlton BrownWinnie BreedenThomas CameronNicole CoxSybil DorseyTammy ElliottMelody HargroveRose HarrisJohn HookerCarmen Jones-BeasleyLauren JohnsonTonya JoynerSaul McCloyenKelli McLeanCourtney McCollumSusan OneyFred ShawWillis SmithTanya Spaulding-SmeltzMing TranChip WoodYouth ProgramKendra BoneyBrandon KeenJimmie ModlinStacy King
20. Other
22. 1st Time at this Location?*

    1. Yes
    2. No
23. Lay Off?*

    1. Yes
    2. No
25. Are you a Veteran?*

    1. Yes
    2. No
26. Registered with the NCWorks.Gov*

    1. Yes
    2. No
28. Confirmation of submission may not be provided though information will be successfully inputted upon submission.
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field