Back to Work Form

Home

18 John St
Lowell, MA 01852
(978) 458-2503

Connecting Workers and Employers

Monday, Tuesday & Wednesday
8:30 am to 5:00 pm
Thursday
8:30 am to 7:00 pm
Friday
9:30 am to 5:00 pm

If you have found employment, Congratulations! We appreciate you providing information so we may continue to receive Federal funding for our programs. ALL INFORMATION IS KEPT CONFIDENTIAL! Filling in this form is your contribution to enabling other unemployed people to continue to have our services available.
Thank you for completing this survey.

Back to Work Form
Name:
Social Security Number or MOSES ID #
Address:
City, State Zip:
Phone Number:
Email Address: (required for reply)
Date:
Employment Information
Company Name:
Company Address:
Company City, State - Zip:
Your Position / Title:
Company Phone Number:
Company E-mail
Job Start Date:
Salary: (please specify hourly or weekly)
Hours Per Week:
Medical Benefits:	Medical Insurance Pension Plan/Social Security No Benefits
Job Information :	Full Time Part Time and Permanent Temporary Contract
Career Center Information
Please check what Career Center services or other source(s) helped you get a job.	Staff Assisted Referral from the Career Center
	Resume Assistance Job Search Workshop(s)
	Newspaper Advertisement Career Center Resources
	Placement Firm Network Contacts
	State Funded Training Self-Funded Training
Please tell us what resources you used:
Did you attend a Career Center Seminar?	Yes No
Did the Career Center Seminar and Status Review Help?	Yes No
Additional Comments:
	Enter the code as it is shown (required):

Home

For questions, comments, or suggestions about this form, please e-mail