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Application Form
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Applicant General Information
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Are you a veteran?
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Type of Discharge:
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Honorable
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Is your spouse a veteran?
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Do you have any problems that will affect your ability to work?
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Current Status (Check all that apply):
Applied for Unemployment
Applied for Food Stamps
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Employed Part-Time
Applied for SSDI
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Unemployed
Applied for SSI
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If yes, please explain:
Goals:
Work History Page
Employer:
Address:
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State / Province / Region
ZIP / Postal Code
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Supervisor:
Type of Work:
Full-Time
Part-Time
Currently Working Here?
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Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Pay/Hour:
Hours/Week:
Job Title:
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Temporary Layoff:
Yes
No
Closure:
Yes
No
Permanent Layoff:
Yes
No
Labor Dispute:
Yes
No
Fired:
Yes
No
If yes, explain:
Quit:
Yes
No
If yes, explain:
Employer:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number:
Supervisor:
Type of Work:
Full-Time
Part-Time
Currently Working Here?
Yes
No
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Pay/Hour:
Hours/Week:
Job Title:
Duties & Machines Operated:
Temporary Layoff:
Yes
No
Closures:
Yes
No
Permanent Layoff:
Yes
No
Labor Dispute:
Yes
No
Fired:
Yes
No
Third Choice
If yes, explain:
Quit
Yes
No
If yes, explain:
Employer:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone Number:
Supervisor:
Type of Work:
Full-Time
Part-Time
Currently Working Here?
Yes
No
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Pay/Hour:
Hours/Week
Job Title:
Duties & Machines Operated:
Temporary Layoff:
Yes
No
Closures:
Yes
No
Permanent Layoff:
Yes
No
Labor Dispute:
Yes
No
Fired:
Yes
No
If yes, explain:
Quit:
First Choice
Second Choice
Third Choice
If yes, explain:
Education Page
Highest Grade Completed:
Select
H.S. Fresh
H.S. Soph
H.S. Junior
H.S. Senior (did not obtain diploma)
H.S. Senior (obtained diploma)
Col. Fresh
Col. Soph
Col. Junior
Associates Degree
Bachelors Degree
Masters
Doctorate
H.S Diploma:
Yes
No
GED:
Yes
No
College Attending/Attended:
Year Degree Obtained:
Assoc. Degree
Program:
College:
Year:
Bach. Degree
Program:
College:
Year:
Master's Degree
Program:
College:
Year:
Doctorate:
Program:
College:
Year:
Are you currently attending School?
Yes
No
If yes, are you full-time?
Yes
No
If yes, where and when will you complete your degree of certification?
Have you completed a FAFSA appliation?
Yes
No
If yes, have you been awarded the Pell grant?
Yes
No
Please list all certifications, degrees, and/or licenses you have earned. Please include the dates, the type of degree/certification, and the institution's name from which they were earned:
Please check any issues/concerns that you feel may be potential barriers to your education and/or employment success:
Legal
Family
Lack of Job Skills
Other
Age
Health (physical and/or mental)
Limited Math Skills
Math Skills
Disability
English Skills
Have you ever been convicted of a felony?
Yes
No
County:
State:
Date:
Have you ever been convicted of a misdemeanor?
First Choice
Second Choice
Third Choice
County:
State:
Date:
Collateral Contacts Page
Fill in information about Collateral Contacts:
Name:
Relationship:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home/Cell Number:
Work Number:
Ext:
Name:
Relationship:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home/Cell Number:
Work Number:
Ext:
Status:
Married
Single
Divorced
Widowed
Other
Including yourself, list names of individuals living with you in household on a FULL TIME basis (name, relationship, age):
Is your spouse employed?
Yes
No
If yes, where?
Do you have children NOT living in the home?
Yes
No
If yes, list full names & ages:
Are you paid child support for them?
Yes
No
If yes, enter amount:
Do you pay child support for them?
Yes
No
If yes, enter amount:
Are you pregnant (if male, is partner)?
Yes
No
Third Choice
Do you have childcare while working or attending employment sessions?
Yes
No
Do you need help in obtaining or paying for childcare?
Yes
No
Do you participate in All Kids Care?
Yes
No
Do you have access for medical care for you and your family?
Yes
No
Consent Form
In compliance with the Family Educational Rights and Privacy Act (FERPA) and the Workforce Innovation & Opportunity Act of 2014, Workforce Investment Solutions, as the administrative entity of Title I funds, is responsible for the security and maintenance of customer records and educational records and for monitoring release of information related to those records. It is understood that the information shared between staff from any organization or agency is confidential in its nature and is used solely for the purpose of providing high quality services to you as a customer. It is further understood by the staff, who will be working with you, that they are responsible for maintaining the highest standards as described in FERPA and WIOA in accessing and using customer records in the daily operation of the One Stop Center. Records are to be maintained in a confidential manner, away from access from non-personnel who may be in the Center as a visitor, a customer, or for any other purpose. I understand that Workforce Investment Solutions will need information about my employment in order to provide outcome information for this federally funded program. At a minimum, we will need the following information regarding current, past, and future employment: date of hire, employer’s name, address, phone, job title, job description, work hours, salary, fringe benefits, and supervisor’s name. In addition, copies of pay stubs may be required. Authorization for Disclosure of Information (Initial Each Statement)
I authorize the release of records and information to other agencies and/or individuals by Local Workforce Area 19 as necessary to enhance or develop my employability skills. I understand staff will contact former employers and/or other agencies to verify information I provide.
I give my consent for institutions and/or other agencies to release information regarding my academic progress, testing results, and any other pertinent information that would be relevant to my educational process.
I have received the orientation to the Workforce Innovation & Opportunity Act of 2014, rights and responsibilities’ including Equal Opportunity is the Law and grievance/hearing procedures.
I understand that I may be contacted for a follow-up survey within 1 year after I enter employment. I also understand that customer satisfaction surveys will be conducted and I may be contacted to give feedback as to the services I received.
I understand the Workforce Innovation & Opportunity Act of 2014 is not an entitlement program, and any services or enrollment is contingent upon funding, as well as my adherence to the conditions of the individual performance contract.
I certify that I have read and understood the above description of the disclosure of information. I hereby authorize to provide other agencies with all personal information that has been provided by me, or obtained by any or all partner organizations in meeting my needs as a customer. This consent is granted until such time that I am no longer eligible for services offered through Workforce Investment Solutions.
I have been informed of the employment-related rights and benefits under the Jobs for Veterans Act.
Customer Signature:
Date
MM slash DD slash YYYY
Parent/Guardian Signature (if applicable):
Date
MM slash DD slash YYYY
Staff Signature:
Date
MM slash DD slash YYYY