Section 1: Business Information

Business Name:

Business Type/Industry:

Business Website (if available):

Primary Contact Name:

Title/Role:

Phone Number:

Email Address

Business Address:

Section 2: Worksite Details

Which of the following industries best describe your business?
(Check all that apply)

TransportationConstruction/Building TradesInformation TechnologyAdvanced ManufacturingRetailHospitalityOther
If Other, explain:

Briefly describe the type of tasks or job duties the participant would perform:

What days and times are you available to host a participant?
(Check all that apply)

Weekday MorningsWeekday AfternoonsWeekendsFlexible

How many participants are you willing to host at a time?

123Other
If Other, please state:

How long are you open to hosting a participant?

4 weeks8 weeksUp to 12 weeks

Are you open to hiring the participant at the end of the placement if there’s a good fit?

YesNoMaybe

What qualities would make a participant a good fit for your business?
(e.g., punctuality, willingness to learn, communication)

Are you open to meeting the participant before placement?

YesNoMaybe

Does your worksite have staff available to provide basic supervision and support?

YesNoNot sure – would like to discuss

What is the typical hourly wage or salary range you would offer for this position if it were paid by your business? (This helps us assess growth potential and fair market value for the participant.)

Hourly: $

Weekly: $

Monthly: $

Other (please specify):

Signature:

Date:

Gang Alternative, Inc. staff will follow up within 3–5 business days to discuss next steps and potential matches.

For more information, contact: Pamela Rollins at prollins@myga.org, 786.391.2375