NC Works Next Gen Prescreen
Please complete ALL SECTIONS of this form, as incomplete sections may cause a delay in processing. Once your form is received, a staff member will follow up with you soon.
Name:
*
First Name
Last Name
E-mail
*
example@example.com
Contact Number
*
Would you like to receive text messages regarding this referral at this number?
*
Please Select
Yes
No
*Data Rate may apply
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
Age
*
Are you a Veteran or a spouse of a Veteran?
*
Please Select
Yes
No
Are you registered with NC Works?
Please Select
Yes
No
If no, please visit ncworks.gov to register.
Are you currently attending school? (high school, college, GED)
Please Select
Yes
No
*Please note that in-school Youth are subject to additional eligibility requirements*
What is your highest level of education?
Please Select
Bachelors Degree
Associates Degree
Some college
GED
High School Diploma
11th grade
10th grade
9th grade
8th grade
Do you identify as having a disability?
Please Select
Yes
No
If you answered "YES", please describe your disability
Do you have documentation to provide for your disability?
Please Select
Yes
No
Are you receiving SSI or SSDI?
Please Select
Yes
No
Are you receiving EBT, TANF, Work First, or any other benefits?
Please Select
Yes
No
Are you receiving unemployment?
Please Select
Yes
No
It is pending/recently applied
Are you currently employed?
Please Select
Yes
No
If you answered "YES", please list the following below: Name of Company, Job Title Hourly Wage, Part Time or Full Time
Is your end goal employment?
Please Select
Yes
No
Are you pregnant or parenting?
Please Select
Yes
No
If you are parenting, do you have adequate childcare? If you are not a parent, choose N/A
Please Select
Yes
No
N/A
If you do not have adequate childcare, what are your plans to manage childcare while in the program?
Are you currently or formerly in the foster care system?
Please Select
Yes
No
Are you currently experiencing or at risk of experiencing homelessness?
Please Select
Yes
No
Do you have adequate transportation?
Please Select
Yes
No
Do you have any misdemeanor and/or felony charges, pending charges, dismissed charges, plea agreements, convictions, etc.?
*
Please Select
Yes
No
If you answered YES, please describe what is listed on your background
Are you currently on probation or parole?
*
Please Select
Yes
No
Please describe your career plan/goals to accomplish with the Next Gen program:
*
Please share any additional information that is helpful for staff to know:
Referral Source (Enter who referred you to the Next Gen Program -Ex: Agency, School, Self, etc.)
Referral Source Contact Information (Phone Number and/or Email) *If you referred yourself, enter N/A)
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