Student Registration

* First Name:	* First Name is required.	* Last Name:	* Last Name is required.
*SSN: -- Enter a valid social security number *Re-enter SSN: -- Enter a valid social security number *Student ID: --		* Date of Birth:	/ /   ( MM / DD / YYYY ) Date of Birth is Required
Gender:	Female Male	* Ethnicity:	Please Select... American Indian/Alaskan Native Asian Black/African American Haitian Hispanic Native Hawaiian/Other Pacific Islander White I do not wish to answer An answer is required
*Number living in household?	Please select... 1 2 3 4 5 6 7 8 9 10 11 12 A number in household is required	*Family income:	An income amount is required Required Field

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* Are you receiving any public assistance: TANF, foster care services, food stamps, or Supplemental Security Income?	Yes   No * Answer is required.
* Are you currently enrolled in a CareerSource South Florida program?	Yes    No * Answer is required.

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Are you currently living on campus (FMU)?

Yes    No

*Current Address:	(Example: 7300 NW 19th Street) House Number: Direction: Street Name: Street Type: Apt: None E N NE NW S SE SW W None AVE AVE CIR AVE CT AVE DR AVE PL AVE RD BLVD BES CT CIR CIR CT CIR DR CIR LN CIR PL CIR TER CONC CSWY CT BLVD CT CIR CT RD DR DR CIR HWY IS IS RD LN LN CIR LN DR LN RD MILE PASS PATH PKWY PL PL CIR PL CT L RD PL WAY PLZ PSGE PT PT DR RD RD DR RD PL ST ST CIR ST CSWY ST CT ST DR ST PL ST RD SQ TER TER CIR TER DR TER RD TER WAY TRL WAY (Ex: 7300) (NW) (19) (St)    *House Number is required. *Numbers Only *Street Name is required.
*State:	Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *State is required.
*City:	Please select... *City is required.
*Zip Code:	Zip code is required *Zip code is required.	* Telephone:	() - * Enter a valid Phone.

Permanent Address:	Check here if this is the same as your current address.
	Check here if your permanent address is inside the U.S.
*Country:	*Country is required.
*State:	Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *State is required.
*City:	Please select... *City is required. *City is required.
*Zip Code:	*Zip code is required

*School / FMU Email:

Email is invalid *Email is required.

*Personal Email:

Permanent Email is invalid *Personal Email is required.

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*Are you attending school?	Yes No *Answer is required	*Highest Level of Education Completed: Please select... 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade GED High School Graduate Associate Degree Bachelor Degree Master Degree Doctorate Degree No Formal Schooling *An education completed level is required
*What is your Major:
* Are you a U.S. Citizen?	Yes No * U.S. citizen answer is required.
*Have you registered with the Selective Service?		Yes No * Selective service answer is required.

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Are you currently in a Work Study or Internship?		Yes No
Employer's Name:		Position/Title:
Skills/Duties: (Max 200 Chars)

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What careers are you interested in?
Choose a Occupation Family	Please select... Architecture and Engineering Occupations Arts, Design, Entertainment, Sports, and Media Occupations Building and Grounds Cleaning and Maintenance Occupations Business and Financial Operations Occupations Community and Social Service Occupations Computer and Mathematical Occupations Construction and Extraction Occupations Education, Training, and Library Occupations Farming, Fishing, and Forestry Occupations Food Preparation and Serving Related Occupations Healthcare Practitioners and Technical Occupations Healthcare Support Occupations Installation, Maintenance, and Repair Occupations Legal Occupations Life, Physical, and Social Science Occupations Management Occupations Military Specific Occupations Office and Administrative Support Occupations Personal Care and Service Occupations Production Occupations Protective Service Occupations Sales and Related Occupations Transportation and Material Moving Occupations
Choose an Occupation	Please choose a job family

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Are you requesting auxiliary aids and services for individuals with disabilities?	Yes    No * Answer is required.

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Please be sure to select your top choice for occupation.

For information, call: 305-626-3734

CareerSource South Florida is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice phone numbers listed on the page may be reached by dialing the Florida Relay # 711