WIOA On-the-Job Training Application

WIOA ADULT AND DISLOCATED WORKER APPLICATION – On-the-Job (OJT) Training
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.
Date

Month Day Year
Date
Full Name
Social Security #
Last four digits only
Physical Address

Address

Street Address Line 2

City State (abbreviation)

Zip Code
County *
County of Residence
County *
Please choose the county in which you currently reside.
Mailing Address
(if different than physical address)
City
State
Abbreviation
ZIP
Home Phone
Cell Phone
Email
example@example.com
The person listed below does not live with me but can always contact me.
Name:
Relationship:
Telephone:
Race/Ethnicity (check all that apply):

African American/Black American Indian or Alaskan Native Asian Hispanic Heritage Caucasian/White Hawaiian or Pacific Islander Prefer not to answer
Gender:

Male Female
Date of Birth:

Month Day Year
U.S. Citizen or Naturalized? *

Yes No
If no, Authorized to Work in U.S.?

Yes No
If yes, list Alien Registration #
Expiration Date:

Month Day Year
Selective Service Compliance

Yes No NA
Disability Status

Yes No Prefer not to answer
Do you have a State Driver’s License?

Yes No
Driver's License Type

Regular Commercial (CDL) CDL Endorsements
Driver's License Class

A B C Other
Has your license ever been or/is currently suspended or revoked?

Yes No
Do you have a State ID?

Yes No
Public Assistance

Individual or member of a family that is receiving, or in the past 6 months has received, the following:
Temporary Assistance for Needy Family (TANF)

Yes No
Food Stamps (SNAP)

Yes No
Supplemental Security Income

Yes No
Other Assistance

Yes No
Comments
(Public Assistance)
Highest Grade Completed:
Highest Credential Earned

HSD/GED Certificate Associates Bachelors Masters PhD None
List degrees/certificates, areas of study
If yes, name of school, and program
Are you currently in school?

Yes No
Anticipated completion date

Month Day Year
List any current professional license(s) you hold:
Veterans and Qualified Spouses Information
Veteran Status: *

Not a Veteran Veteran Qualified Spouse of a Veteran Transitioning Service Member
Branch of Service:

Air Force Army Coast Guard Navy U.S. Marines
Dates of Service--From:
Dates of Service--To:
Served More than One Tour of Duty

Yes No
Nature of Military Discharge

Honorable Less than Honorable Dishonorable Service Connected Disability
Service Connected Disability

No Disabled Vet Special Disabled Vet
Armed Forces Campaign or Expeditionary Medal

Yes No
Recently Separated: (within 48 months)

Yes No
A BRAC-impacted Worker:

Yes No
Employment Information
Currently employed

Yes No
Have you been affected by the COVID-19 Pandemic?

Yes No
Currently receiving or have received Unemployment Compensation (UI) in the last year?

Yes No
Received severance pay from last employer?

Yes No
If Yes, Amount
Employment History

List current and previous employers of last 3 jobs, beginning with current or most recent job.
Most recent employer:
Address:
Street, City, State, ZIP
Job Title
Type of Business
Phone
Hourly Wage
Hours per week
Shift
Main duties
Equipment Used:
Start date

Month Day Year
Most recent employer
End date

Month Day Year
Most recent employer
Reason for Leaving

Laid off Quit Terminated Other employment Plant closure Other
Previous employer:
Next most recent employer
Address:
Street, City, State, ZIP
Job Title
Type of Business
Phone:
Hourly wage
Hours per week
Shift
Start date

Month Day Year
Next most recent employer
End date

Month Day Year
Next most recent employer
Reason for Leaving

Laid off Quit Terminated Other employment Plant closure Other
Main duties
Equipment Used
Reason for Leaving

Laid off Quit Terminated Other employment Plant closure Other
Previous employer
Next employer
Address
Next employer
Job Title:
Type of business
Phone
Hourly Wage:
Hours per week
Shift:
Main Duties:
Equipment Used
Start Date:

Month Day Year
End Date:

Month Day Year
Date
Reason for Leaving

Laid off Quit Terminated Other employment Plant closure Other
Income Information

(for the adult program only)
Family size:
Number of people in your household
Family member
Name of person working
Source of Income
Income (six months)
Family member
Name of person working
Source of income
Income (six months)
Family member
Name of person working
Source of income
Income (six months)
Total household income
For six months
WIOA RELEASE OF INFORMATION CONSENT/CERTIFICATION AND ACKNOWLEDGEMENT
NAME:
DATE:

Month Day Year
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) Adult and Dislocated 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. By initialing below, I am agreeing to this release of information for eligibility.
Applicant's Initials *

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. By initialing below, I am agreeing to this release of information.
Applicant's Initials *

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 such as the Georgia Department of Labor OJT program, 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. By initialing, I am agreeing to this release. *

Yes No
Applicant's Initials *

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.

By initialing, I affirm that all information is true and correct to the best of my knowledge.

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

Missing documentation will delay the process of your application.
Applicant's Initials *

Clear
NEPOTISM/CONFLICT OF INTEREST
Are you related by blood, marriage, or adoption to anyone on staff of the Service Provider, TCSG, Local Workforce Development Area, Sub-State Grantee, Georgia Department of Labor, or Field Service Office?

Yes No
Applicant's Initials *

Clear
By signing digitally, you are affirming that the above information is true and correct, to the best of your knowledge, and that the releases above are granted. *

Clear
Date: *

Month Day Year
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 Adult DW OJT Only 7/1/20
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WIOA ADULT AND DISLOCATED WORKER APPLICATION – On-the-Job (OJT) Training

Public Assistance

Veterans and Qualified Spouses Information

Employment Information

Employment History

Income Information

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