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CONTACT FORM
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Personal information
First Name *
Middle Name
Last Name *
Second Last Name
Birthday *
Address *
Optional Address Notes
Neighborhood *
Zip Code *
Phone Number *
Email
Extra Personal Information
Gender *
Female
Male
Others
Level of English *
Beginner
Intermediate
Advanced
Native
Do you have a Pennsylvania ID?*
Yes
No
Do you have any disabilities?*
Yes
No
Prefers not to say
Origin Country *
Date of entry to the United States *
Used only for statistical purposes
Estimated date of arrival to Pittsburgh *
Used only for statistical purposes
Family members under 18 *
How many members of your direct family living in your house are under 18 years old?
Adult family members *
How many members of your direct family living in your house are adults?
Estimated monthly household income *
Inquiry Information
Urgency *
Low
Medium
High
What positions are you looking for? *
Expected Pay
$
What type of job are you looking for? *
Part time
Full time
What are your skills?
What is your availability to start working? *
Immediately
Already working
Current Pay
$
List your last jobs
Why you would like to leave your current job?
Notes
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