Applicant Name
*
First Name
Last Name
Mailing Address
*
Mailing Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Format: (000) 000-0000.
Alternate Number Phone
Format: (000) 000-0000.
Applicant Email Address
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Last 4 of SSN
*
Gender at birth
*
Male
Female
Prefer not to answer
Citizenship (check all that apply)
*
US Citizen
Registered Alien
Refugee
Other Legal Alien
Other
What is your ethnicity?
*
Latino
Not Latino
I Prefer Not to Answer
What is your race? (check all that apply)
*
African-American
White
Asian
American Indian / Alaska Native
Hawaiian Islander / Other Pacific Islander
Other
Are you legally restricted from using a computer?
*
Yes
No
Emergency Contact
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Relationship Disclosure
Do you have a business or personal relationship with any individual who is a:
Local elected official (mayor or county commissioner);
Workforce Development Board member or subcommittee member;
WIOA executive, supervisor or employee;
OhioMeansJobs center partner employee, WIOA sub-recipient and/or contractor; or
County employee?
Business Relationship?
*
Yes
No
Name of Individual with Business Relationship
First Name
Last Name
ClientGuid
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Education
Highest grade completed
*
What is your education level?
*
Current high/junior high school student
Withdrew f rom high school, no HS diploma
Completed 12th grade, but no HS diploma
Obtained certificate of equivalency for high school diploma
High school graduate
Some post high school education, no degree
College degree
College degree
Associate
Bachelor
Masters/Prof.
What is your education status?
*
I am not a student
I am a student at a college or technical school
I am a student in a HS equivalency program
I am a high school student, at grade level
I am a high school student, behind grade level
Do you have work experience in Agriculture within the last 12 months?
*
Yes
No
Have you served in the US Military?
*
Yes
No
Active Military Start Date
/
Month
/
Day
Year
Date
Active Military End Date
/
Month
/
Day
Year
Date
Are you a Spouse of a Veteran?
*
Yes
No
Are you a Homeless Veteran?
*
Yes
No
Do you hold a valid Driver’s License?
*
Yes
No
Type of Driver's License
Non-Commercial
CDL
CDL A
CDL B
CDL C
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WIOA Information
Are you interested in an Apprenticeship?
*
Yes
No
Have you registered for Selective Service (for males 18 or older)?
*
Yes
No
Exempt
If registered for Selective Service enter your SSR Number
Are you enrolled in ASPIRE?
*
Yes
No
Have you received OWF for 1 or more years?
*
Yes
No
Are you a public assistance recipient (cash/food)?
*
Yes
No
Are you enrolled in Vocational Rehab through OOD?
*
Yes
No
Are you receiving SNAP Employment and Training?
*
Yes
No
Do you have a disability?
*
Yes
No
Type of Disability
Physical
Mental
Learning
Are you a runaway?
*
Yes
No
What is your native or primary language?
*
Please Select
English
Spanish
Swahili
Arabic
Nepali
American Sign Language (ASL)
Other
If English is not your native or primary language, do you need help learning to speak/write/use English?
*
Yes
No
Have you taken a recent math/reading assessment?
*
Yes
No
Do you use recreational drugs or drink regularly?
*
Yes
No
Are you a single parent?
*
Yes
No
Do you think you have a cultural barrier that might hinder employment?
*
Yes
No
Are you homeless?
*
Yes
No
Are you involved or were you involved in the juvenile court or adult justice system?
*
Yes
No
Are you in foster care or were you previously in foster care?
*
Yes
No
Are you pregnant?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Are you a parent (including noncustodial)?
*
Yes
No
Have you received a Pell Grant?
*
Yes
No
Is your family eligible to receive free/reduced price lunch?
*
Yes
No
Other Information
Are you a fugitive felon?
*
Yes
No
Have you fraudulently received TANF assistance?
*
Yes
No
Are you pregnant with your first child?
*
Yes
No
Are you a non-custodial parent?
*
Yes
No
Other Eligibility
Is the youth participant in an OWF assistance group?
*
Yes
No
Is the youth participant in a SNAP (food assistance) assistance group?
*
Yes
No
Is the youth participant a member of a household receiving subsidized childcare?
*
Yes
No
Is the youth participant in the temporary or permanent custody of a public children’s service agency?
*
Yes
No
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TANF Funding Eligibility
This section determines eligibility for TANF-funded services.
Have you or anyone you are living with been ordered to repay cash assistance (OWF), due to a determination of fraud and still owe repayment? If YES, skip to ‘Acknowledgement’ section.
*
Yes
No
Are you currently receiving cash assistance? If YES, skip to ‘Acknowledgement’ section.
*
Yes
No
Are you currently receiving SNAP? If YES, skip to ‘Acknowledgement’ section.
*
Yes
No
Household Members Monthly Income
Complete the table below indicating each household member’s monthly income.
Name (Self)
First Name
Last Name
Relationship
Please Select
Self
US Citizen?
Please Select
Yes
No
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Applicant SSN
Hourly / Weekly Wage
Monthly Income
Source of Income
Relative 1
Name
First Name
Last Name
Relationship
Please Select
Wife
Mother
Father
Son
Daughter
Brother
Sister
Grandfather
Grandmother
Aunt
Uncle
US Citizen?
Please Select
Yes
No
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Hourly / Weekly Wage
Monthly Income
Source of Income
Relative 2
Name
First Name
Last Name
Relationship
Please Select
Wife
Mother
Father
Son
Daughter
Brother
Sister
Grandfather
Grandmother
Aunt
Uncle
US Citizen?
Please Select
Yes
No
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Hourly / Weekly Wage
Monthly Income
Source of Income
Relative 3
Name
First Name
Last Name
Relationship
Please Select
Wife
Mother
Father
Son
Daughter
Brother
Sister
Grandfather
Grandmother
Aunt
Uncle
US Citizen?
Please Select
Yes
No
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Hourly / Weekly Wage
Monthly Income
Source of Income
Relative 4
Name
First Name
Last Name
Relationship
Please Select
Wife
Mother
Father
Son
Daughter
Brother
Sister
Grandfather
Grandmother
Aunt
Uncle
US Citizen?
Please Select
Yes
No
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Hourly / Weekly Wage
Monthly Income
Source of Income
Relative 5
Name
First Name
Last Name
Relationship
Please Select
Wife
Mother
Father
Son
Daughter
Brother
Sister
Grandfather
Grandmother
Aunt
Uncle
US Citizen?
Please Select
Yes
No
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Hourly / Weekly Wage
Monthly Income
Source of Income
Section
Do you have a child under age 18 or 18 who is attending high school full-time?
Yes
No
Number of children
Oldest child age
Are you one of the following (check all that apply):
*
A minor child (including age 18 attending high school fulltime)
A parent, specified relative, legal guardian or legal custodian of a minor child
A non-custodial parent
A pregnant individual
An individual age 18-24 that is part of a family that includes a minor child?
Have you been given the opportunity to register to vote?
*
Yes
No
N/A (age 16 or under)
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Acknowledgement
By signing, I attest that the information stated on this application is true and accurate. I understand that if the information or income provided was misrepresented, it may be grounds for immediate termination in the CCMEP program and/or penalties as specified by law. If the applicant is under age 18, the parent/guardian signature below gives permission for the youth to participate in CCMEP services and activities.
*
I have received a copy of the JFS Form 08063 "Complaint Rights under the Workforce Innovation and Opportunity Act (WIOA)".
Applicant Signature
*
Date
*
/
Month
/
Day
Year
Date
Proof of Income
You will be required to provide proof of eligibility for this program.
Driver's License, State ID or Passport
*
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Additional Eligibility Documents (Optional)
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Paystubs, Proof of Income, etc
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of
Additional Eligibility Documents (Optional)
Browse Files
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Choose a file
Paystubs, Proof of Income, etc
Cancel
of
Additional Eligibility Documents (Optional)
Browse Files
Drag and drop files here
Choose a file
Paystubs, Proof of Income, etc
Cancel
of
Parent/Guardian Signature (If applicant is underage 18*
Date
/
Month
/
Day
Year
Date
Save
Submit
Should be Empty: