Good Life Solutions Interest Form

2. First Name*

3. Last Name*

5. Street Number*

6. Street Name*

7. Street Type*

8. Apt #

10. City*

11. State*

12. ZIP

14. Home Phone

15. Cell Phone

16. Email*

18. Current Education Year*

19. Area of Interest*

21. List any courses relevant to the job opportunity you are seeking:

23. Have you been employed during the past 6 months?

25. Dates Employed:

27. From:

28. To:

30. Employer:

31. Position Title:

33. Address (Street, City, State, Zip Code):

35. Supervisor Name:

36. Supervisor Phone Number:

37. Supervisor Title:

39. Hours per week:

40. Salary:

41. May we contact this employer?

    1. Yes
    2. No

43. Duties

45. Reason for leaving:

47. List any other paid or unpaid work experience as it relates to the job you are seeking:

49. List other training, qualifications, and special interests (licenses, skills with machines, publications, memberships in professional or scientific societies):

51. Number of hours required to fulfill education program requirements (if applicable):

52. Schedule availability / preference (list days and times):*

54. Are you currently employed by the City of Newport News?*

    1. Yes
    2. No

55. Do you currently have any relatives working for the City of Newport News?*

    1. Yes
    2. No

57. Relative's Name, Relationship, and Department

59. Please provide your current GPA:

61. You may attach an electronic version of your resume:

Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field