WIOA Application for COVID/Disaster

WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) DISLOCATED WORKER TRAINING APPLICATION

COVID-19 Related
In order to be eligible for the WIOA Program through Worksource Northwest Georgia, you must reside in or have been laid off from employment in one of the 15 counties in Northwest Georgia: Bartow, Catoosa, Chattooga, Dade, Fannin, Floyd, Gilmer, Gordon, Haralson, Murray, Paulding, Pickens, Polk, Walker, or Whitfield.
Applicant Information
Date

MonthDayYear
Date
TrainingWork Experience
County *
Please choose the county in which you currently reside
Full Name:
Social Security # (Last 4 Digits):
Last four digits only
Address

Physical Address

Street Address Line 2

CityState (abbreviation)

Postal / Zip Code
Address

Address

Street Address Line 2

City

Zip CodeState
Mailing Address

Mailing Address (if different)

Street Address Line 2

CityState

Postal / Zip Code
County*
County of Residence
Home Phone
Cell Phone
Email
example@example.com
Contact Information
The person listed below does not live with me but can always contact me.
Name:
Relationship:
Telephone:
Demographic Information
African American/BlackAmerican Indian or Alaskan NativeAsianHispanic HeritageCaucasian/WhiteHawaiian or Pacific IslanderPrefer Not to AnswerOther
Male:Female
Date of Birth:

MonthDayYear
Date
YesNo
YesNo
If yes, list Alien Registration #
Alien Registration Date:

MonthDayYear
Date
YesNoPrefer Not to Answer
YesNoNA
Driver’s License/State ID Information
YesNo
RegularCommercialCDL Endorsements
ABCOther
YesNo
YesNo
Public Assistance (If Yes, Provide Verified Documentation)

Individual or member of a family that is receiving, or in the past 6 months has received, the following:
YesNo
YesNo
YesNo
YesNo
Comments
Public Assistance
Education History
Highest Grade Completed:
Highest Credential Earned:CertificateAssociatesBachelorsMastersPhDNone
List degrees/certificates area(s) of study:
YesNo
List any current professional license(s) you hold:
yes, Name of School, Program, Anticipated completion date

MonthDayYear
Date
Veterans and Qualified Spouses Information
Name:
Not a VeteranVeteranQualified Spouse of a Veteran (see Eligibility Manual for information)Transitioning Service Member
Information in this section applies to Veterans only (Provide Documentation of DD-214 form - https://vetrecs.archives.gov/)
Air ForceArmyCoast GuardNavyU.S. Marines
NoDisabled VetSpecial Disabled Vet
Dates of Service:
From

MonthDayYear
Date
To

MonthDayYear
Date
HonorableDishonorableLess than HonorableService Connected Disability
YesNo
YesNo
YesNo
YesNo
(BRAC may be considered eligible as Dislocated Worker)
Employment Information
YesNo
YesNo
Temporarily or permanently laid off as a consequence of COVID-19..A dislocated workerA long-term unemployed worker unemployed for 27 or more consecutive weeks.A self-employed individual who became unemployed or significantly under-employed as a result of the disaster or emergency.
YesNo
Amount $
Employment History
List current and previous employers of last 3 jobs, beginning with current or most recent job.
Most recent employer:
Job Title:
Address
Street, City, State, ZIP
Type of Business:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Hourly Wage
Hours per week
Shift
Phone:
Main Duties:
Equipment Used:
Laid OffQuitTerminatedOther EmploymentPlant ClosureOther
Previous employer:
Job Title:
Address:
Type of Business:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Hourly Wage:
Hours per week:
Shift:
Phone:
Main Duties:
Equipment Used:
Laid OffQuitTerminatedOther EmploymentPlant ClosureOther
Previous employer:
Job Title:
Address
Type of Business
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Phone
Hourly Wage
Equipment Used:
Hours per week
Shift
Laid OffQuitTerminatedOther EmploymentPlant ClosureOther
Main duties
WIOA RELEASE OF INFORMATION CONSENT/CERTIFICATION AND ACKNOWLEDGEMENT
NAME:
DATE:

MonthDayYear
Date
RELEASE INFORMATION FOR ELIGIBILITY
I authorize the release of my information to the Career Advisor as necessary to determine my eligibility for the Workforce Innovation and Opportunity Act (WIOA) Dislocated Worker programs and services. I further authorize the release of information by staff necessary to secure related services and assistance on my behalf and share information with other programs from which I receive or have received services such as Vocational Rehabilitation, Division of Family & Children Services (DFACS), and the Department of Labor (DOL This authorization to gather information about me and share necessary and pertinent personal information about me is given with the understanding that the information will be used in a confidential and responsible manner.
Initial*

Clear
RELEASE INFORMATION FOR EMPLOYMENT
I authorize the release of my past, current, and future employment information to the Career Advisor. Such records include information related to my employer’s name, job title, start/end date, hourly wages and hours worked per week.
Initial*

Clear
PHOTOGRAPH RELEASE
I hereby authorize the Workforce Innovation and Opportunity program in Northwest Georgia including the WIOA staff of The Northwest Georgia Regional Commission and its contracted WIOA program service providers to use my photograph or video image in conjunction with my name (or fictitious name) for sale of or reproduction in any medium for the purpose of advertising, display, audiovisual exhibition or editorial use.
YESNO
Initial*

Clear
CERTIFICATION AND ACKNOWLEDGEMENT
I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for WIOA program and activities and may be considered justification for dismissal if discovered at a later date. I acknowledge that my Personal Identifying Information (PII) will be used for grant purposes only. I acknowledge that I have been informed of all available WIOA training activities in this area.

I understand that my eligibility for WIOA and/or referral to a WIOA training Contractor DOES NOT mean that I have been automatically accepted into that Contractor’s training program.

I acknowledge that in accordance with Section 680.210 of the Federal Register and WIOA Section 134(c3A), of the ACT, WIOA is not an entitlement program.

Applicants are responsible for ensuring that ALL required documentation is attached to their application

Missing documentation will delay the process of your application.
Initial*

Clear
NEPOTISM/CONFLICT OF INTEREST
YesNo
Initial*

Clear
Please read the above carefully, initial each release/acknowledgement, sign and date. By signing your name in the box below, you affirm that all information provided herein is correct and true to the best of your knowledge.
Applicant's Signature:*

Clear
Date*

MonthDayYear
Date
FOR OFFICE USE ONLY
DISLOCATED WORKERCOVID-19 RELATED
Veteran or Eligible SpouseLow-IncomePublic AssistanceBasic Skills Deficient
Interviewer's Signature
Date:

MonthDayYear
Date
Second Reviewer's Signature
Date

MonthDayYear
Date
In accordance with 29 CFR 38.9 (g3), Limited English Proficient (LEP) individuals through Northwest Georgia Worksource Georgia, will receive language assistance in all communications of vital information. Vital information is defined as information whether written, oral or electronic, that is necessary for an individual to understand how to obtain any aid, benefit, service, and/or training; necessary for an individual to obtain any aid, benefit, service, and/or training; or required by law. An interpreter, as well as the availability of free language assistance such as rulebooks; written test that do not access English language competency, but rather assess competency for a particular license, job, or skill for which English proficiency is not required; and letters or notices that require a response from the beneficiary or applicant, participant, or employee will be provided to all LEP individuals at no cost to the individual. (29 CFR § 38.4(ttt)

TO ACCESS AN INTERPRETER CALL NORTHWEST GEORGIA REGIONAL COMMISSION WIOA DEPARTMENT AT 706.295.6485

An Equal Opportunity Employer/Program. Auxiliary Aids and Services Upon Request to Individuals with Disabilities TTY/TDD 1.800.255.0056 Application DW COVID-19 Related 7/20
Should be Empty:

WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) DISLOCATED WORKER TRAINING APPLICATION

Contact Information

Demographic Information

Driver’s License/State ID Information

Public Assistance (If Yes, Provide Verified Documentation)

Education History

Veterans and Qualified Spouses Information

Dates of Service:

Employment Information

Employment History

WIOA RELEASE OF INFORMATION CONSENT/CERTIFICATION AND ACKNOWLEDGEMENT

RELEASE INFORMATION FOR ELIGIBILITY

RELEASE INFORMATION FOR EMPLOYMENT

PHOTOGRAPH RELEASE

CERTIFICATION AND ACKNOWLEDGEMENT

NEPOTISM/CONFLICT OF INTEREST

FOR OFFICE USE ONLY