Department of Labor - Central Intake/Referral Form
Please select which type of assistance you are applying for
*
G.E.D. Assistance
Employment Assistance
Training Assistance
Work Experience (8-week)
Driver's License Reinstatement Reimbursement
Name
*
First Name
Middle Initial
Last Name
Social Security Number
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Gender
*
Male
Female
DOB
*
-
Month
-
Day
Year
Date
Age
*
Cultural Identification
*
American Indian
Alaskan Native
Hawaiian Native
Non-Native
Tribe
CDIB (if applicable)
Browse Files
Cancel
of
Educational Status
*
Student
HS Dropout
HS Graduate
GED Graduate
Post High School
College Graduate
Last Grade Completed
*
Housing
*
Own
Rent
Free Housing
Homeless
C&A Housing Authority Resident
*
Yes
No
Public Assistance Received
*
SNAP/Commodities
Hope/Elder Care
TANF
General Assistance
SSI
WIC
SSDI
N/A
Veteran Status
*
Honorably Discharged
Recently Separated
Disabled
Other: Active Duty/Guard/Reserve
Not a Veteran
Selective Service Registration (Males 18-25)
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Registered
Not Registered
Exempt
Not Applicable
Selective Service Registration #
*
Barriers to Employment
*
High School Incomplete
Individual with a Disability
Offender
Basic Skills Deficient (less than 9th grade)
Public Assistance Request
Homeless, Runaway, or Foster Child
Substance Abuse
Displaced Homemaker
Pregnant or Parenting Youth
Transportation
Single Head of Household w/Dependent Under age 18
Limited Work History
N/A
Number of Dependents Under 18
*
Do you have any other barriers to employment not listed above?
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Employment Status
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Employed
Under Employed
Unemployed
Long-Term Unemployment (15 of the past 26 months)
Benefits Received?
*
Yes
No
Marital Status
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Single
Married
Separated
Divorced
Transportation
Drivers License?
*
Yes
No
Drivers License Number
Dependable Transportation?
*
Yes
No
Type of Transportation
Personal Car
Family Vehicle
Child Care
*
Not Applicable
Need
Currently Have
Number of Children Under Age 12
*
Type of Current Child Care
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Center
Provider Home
In Home
Relative
Social Service Needs
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Housing
Transportation
Child Care
Substance Abuse
Parenting
Counseling
Training Needs
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Basic Skills
GED
Occupational Skills Upgrade
On the Job Training
Vocational Short Term
Vocational Long Term
Retraining
Employment Needs
*
Job Search
Employment Referral
Work Experience
Life/Employment Skills
Apprenticeship
Rehab Technology
Work Experience
List most recent employment first
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
*
Date Started
*
Date Ended
*
Hourly Wage
*
Job Duties
*
Previous Job?
*
Yes
No
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
*
Date Started
*
Date Ended
*
Hourly Wage
*
Job Duties
*
Previous Job?
*
Yes
No
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
*
Date Started
*
Date Ended
*
Hourly Wage
*
Job Duties
*
Education Experience
Do you have a resume?
*
Yes
No
Upload your Resume
*
Browse Files
Cancel
of
High School?
*
Yes
No
High School Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other High Schools Attended
*
Graduation Year
*
Last Grade Completed
*
9th
10th
11th
12th
In What Year did you last attend High School?
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Vocational School?
*
Yes
No
Vocational School Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Course Name
*
Date Started/Finished
*
Certification Earned and Year it was Earned
*
Type n/a if not applicable
2nd Certification Earned and Year it was Earned
*
Type n/a if not applicable
College/University?
*
Yes
No
College/University Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Major/Minor
*
Date Started/Date Completed or Withdrawn
*
Associates Degree and Year
*
Type n/a if not applicable
Bachelors Degree and Year
*
Type n/a if not applicable
Masters Degree and Year
*
Type n/a if not applicable
Certification
I certify that the information provided is true and complete tot he best of my knowledge and that there is no intent to commit fraud or perjury; or I will be subject to immediate termination. I understand that the information provided will be used to determine eligibility for DREAMS program services and subject to review and verification, and taht I may be required to provide documents to substantiate income, benefits, prior and present work history, CDIB and other pertinent documentation to support this application. I further understand that a determination of eligibility is not a guarantee of services. I hereby authorize release of this information for verification purposed understanding all information is confidential and will not be released to any other agency, office, or individual unless the information is necessary to provide me with comprehensive services.
I certify I have reviewed the
DREAMS Program Statement of Privacy
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Initial
Last Name
Submit
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