San Bernardino County, California



SECTION I: Customer Information (Completed by DRC staff)NAME; First, MI, Last: FORMTEXT ?????Last 4 digits SSN: FORMTEXT ????Residential Address: FORMTEXT ?????Residential City & State: FORMTEXT ?????Residential Zip Code: FORMTEXT ?????Mailing Address: FORMTEXT ?????Mailing City & State: FORMTEXT ?????Mailing Zip Code: FORMTEXT ?????Probation Identification Number: FORMTEXT ?????Probation Type (select one): FORMCHECKBOX 109 FORMCHECKBOX 1203 FORMCHECKBOX 1170 FORMCHECKBOX 678SECTION II: Customer Instructions (Completed by DRC staff)INSTRUCTIONS:You are being referred to the San Bernardino County Employment Resource Center selected below for consideration of services.ERC Locations: FORMCHECKBOX High Desert ERC17310 Bear Valley Rd, Suite 109Victorville CA 92395(760) 552-6550 FORMCHECKBOX West Valley ERC9650 9th Street, Suite ARancho Cucamonga CA 91730(909) 941-6500 FORMCHECKBOX East Valley ERC658 Brier Street, Suite 100San Bernardino CA 92415(909) 382-0440REQUIRED documents needed for first ERC visit:Photo I.D. (proof of identity)Document providing date of birth/ageU.S. Social Security cardProof of San Bernardino County residencyDD-214 (if military Veteran)Proof of Unemployment Insurance Eligible/Exhausted/Ineligible (if applicable)SECTION III: Probation-Day Reporting Center Contact Information(Completed by DRC staff)REFERRED BYDRC Staff Member: FORMTEXT ?????Title: FORMTEXT ?????Caseload #: FORMTEXT ?????DRC Locations: FORMCHECKBOX Victorville DRC15505 Civic DriveVictorville CA 92392(909)387-5848 or(909)387-5714 FORMCHECKBOX Rancho Cucamonga DRC9487 Etiwanda Ave.Rancho Cucamonga CA 91739(909) 463-7557 FORMCHECKBOX San Bernardino DRC524 N. Mountain View Ave.San Bernardino CA 92415(909) 387-5848 or(909) 387-5714Telephone Number: FORMTEXT ?????Email Address: FORMTEXT ?????Date Referred: FORMTEXT ?????Signature:SECTION IV: WIA-WDD Contact Information (Completed by WIA-WDD staff)SEEN BYWDD Staff Member: FORMTEXT ?????Title: FORMTEXT ?????Located at (select one): FORMCHECKBOX High Desert ERC FORMCHECKBOX West Valley ERC FORMCHECKBOX East Valley ERCTelephone Number: FORMTEXT ?????Email Address: FORMTEXT ?????Date Seen: FORMTEXT ?????Signature:Comments:____________________________________________________________________________________________________________________________________Recommended services/activities:____________________________________________________________________________________________________________________________________ ................
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