Test Application form – Workforce Investment Solutions

Application Form

Please complete the application form in one sitting. If you exit, the form will not save and you will have to restart!

Application Form

Step 1 of 4

25%

Applicant General Information

First Name:(Required)

Middle Name:

Last Name:(Required)

Maiden Name:

Other Names:

Date of Birth:(Required)

MM slash DD slash YYYY

Gender:(Required)

U.S. Citizen:(Required)

Phone Number:

Email:

Are you registered on Illinois Job Link?(Required)

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ethnicity (Check all that apply):

White

Black

Asian

American Indian/American Native

Native Hawaiian/Pacific Islander

Hispanic: Yes

Hispanic: No

Decline to Answer

Are you a current member of the military?(Required)

Are you a veteran?(Required)

Type of Discharge:(Required)

Is your spouse a veteran?(Required)

Do you have any problems that will affect your ability to work?(Required)

Current Status (Check all that apply):

Applied for Unemployment

Applied for Food Stamps

Receiving SSI

Employed Part-Time

Applied for SSDI

Receiving Unemployment

Receiving Food Stamps (Currently or within last 6 months)

Unemployed

Applied for SSI

Receiving SSDI

Employed Full-Time

Exhausted Unemployment

If yes, please explain:

Goals:

Work History Page

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

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

Closure:

Yes

Permanent Layoff:

Yes

Labor Dispute:

Yes

Fired:

Yes

If yes, explain:

Quit:

Yes

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

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

Closures:

Yes

Permanent Layoff:

Yes

Labor Dispute:

Yes

Fired:

Yes

Third Choice

If yes, explain:

Quit

Yes

If yes, explain:

Employer:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number:

Supervisor:

Type of Work:

Full-Time

Part-Time

Currently Working Here?

Yes

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

Closures:

Yes

Permanent Layoff:

Yes

Labor Dispute:

Yes

Fired:

Yes

If yes, explain:

Quit:

First Choice

Second Choice

Third Choice

If yes, explain:

Education Page

Highest Grade Completed:

H.S Diploma:

Yes

GED:

Yes

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

If yes, are you full-time?

Yes

If yes, where and when will you complete your degree of certification?

Have you completed a FAFSA appliation?

Yes

If yes, have you been awarded the Pell grant?

Yes

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

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

If yes, where?

Do you have children NOT living in the home?

Yes

If yes, list full names & ages:

Are you paid child support for them?

Yes

If yes, enter amount:

Do you pay child support for them?

Yes

If yes, enter amount:

Are you pregnant (if male, is partner)?

Yes

Third Choice

Do you have childcare while working or attending employment sessions?

Yes

Do you need help in obtaining or paying for childcare?

Yes

Do you participate in All Kids Care?

Yes

Do you have access for medical care for you and your family?

Yes

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

Back to homepage

Application Form

Application Form

Applicant General Information

Work History Page

Education Page

Collateral Contacts Page

Consent Form

Get Email Updates

Hours: Monday-Friday 8:30AM-4:30PM

Conflict of Interest Policy

Procurement Policy