MTS Information Seminar	* Optional
Last Name
First Name	Middle
Street Address	Apt. #
City
State	Zip
*Date of Birth	MonthDayYear
*Social Security #	Gender Male Female
Primary Phone #	Marital Status Married Divorced Widowed Never Married Separated Domestic Partner
The highest grade you completed at school	>6 6 7 8 9 10 11 12 GED HS Some College AA/AS BS/BA item MA Phd
How did you hear about MTS?	Friend/Family Member Former Client Doctor/Clinic
	ASO/CBO
	Advertisement (Publication)
	Other Referral Sources
Have you been a client of MTS in the past? Yes No
If yes, please provide dates that you received services from MTS:
Who was your Vocational Counselor?
What benefits are you receiving? SSI SSD PA (Case #)
Veterans DASIS (Case #) Other
MTS Registrations are held at 1 p.m. Thursdays. The Registration includes information on training programs and employment assistance offered by MTS. You will also be asked to complete the Test of Adult Basic Education.
Your next availability?	Date Time 1:00 PM - 4:30 PM
We are only able to enroll individuals who are eligible to work in the United States. Do you have documentation indicating that you are eligible to work in the U.S.? Yes No
Please bring your Social Security Card and a picture ID with you to Registration.
When I call you at the number you provided, may I identify myself as a representative of MTS? Yes No