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Format: (000) 000-0000.
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Format: (000) 000-0000.
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Format: (000) 000-0000.
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- Preferred Contact Method*
- Best Day to Contact You*
- Best Time to Contact You*
- Do you have a Social Media Account? Facebook, Instagram, Twitter, etc*
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Format: (000) 000-0000.
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Format: (000) 000-0000.
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- Applicant Date of Birth*
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- Ethinicity*
- Gender*
- Citizenship*
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- Expiration Date
- Are you registered with Selective Service? (Males ONLY, born ON or AFTER 1/1/1960)*
- Are you pregnant/parenting?*
- Are you homeless?*
- Are you a runaway?*
- Do you consider yourself to have a disability?*
- Do you speak English?*
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- Have you ever been convicted of a criminal offense?
- Highest Credential Earned*
- Highest Grade Completed*
- Are you currently in school?*
- Specify
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- Employment Status*
- Last Date of Employment
- Employment History (Type of business worked in)
- Are you currently looking for work?*
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- Have you worked on a farm or as a migrant/food processor as least 25 days in the past 12 months?*
- Have you been laid off or are you unable to find work due to the COVID-19 Pandemic?*
- Are you receiving Unemployment Insurance?*
- Within the last 12 months, have you received a notice of termination or layoff from your job?*
- Within the last 12 months, have you received documentation that you are separating from military service?*
- If terminated, laid off, received notice of termination or layoff or military separation enter last date of employment
- Have you been supported through the State's Foster Care System? (State or local payments are made for applicant)*
- Have you received Refugee Cash Assistance Payments (RCA)?*
- Do you OR does anyone in your household currently receive, or in the past 6 months have received ANY of the following? *
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- Specify frequency of Household Income
- Are you currently in the military, a Veteran, or the spouse of a Veteran?*
- Are you within 24 months of retirement OR 12 months of discharge from the military?*
- Planned retirement/discharge date
- Have you served on Active Duty in the armed forces and were discharged or released from service under conditions other than dishonorable?*
- Are you a member of the armed forces who is wounded, ill, or injured and receiving treatment in a military facility or warrior transition unit?*
- Are you a caregiver who is a spouse or family member of a member of the armed forces who is wounded, ill, or injured and receiving treatment in a military facility or warrior transition unit?*
- Are you the spouse of a veteran who: has a total service-connected disability; died from a service-connected disability; is Missing in Action, captured in the line of duty by a hostile force, or is a Prisoner of War?*
- RELEASE OF INFORMATION FOR ELIGIBILITY (INITIALS REQUIRED): I authorize the release of my information to the Case Manager as necessary to determine my eligibility for the Workforce Innovation and Opportunity Act (WIOA) Adult Dislocated and/or Youth 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 (DFCS) and Department of Labor. 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 confidential and responsible manner.*
- RELEASE OF INFORMATION FOR EDUCATIONAL INSTITUTION (INITIALS REQUIRED): I authorize the release of my current, past, and future educational records from high schools, colleges, universities, and training schools to the Case Manager. Such records include my current/past enrollment, transcripts, attendance records, graduation/completion information and diploma/certification/credential attained. I understand that under the Family Educational Rights and Privacy Act of 1974 (FERPA), which is a federal law that protects the privacy of student education records, that the Case Manager must have my written consent to obtain my educational records. I certify that this authorization of release form may be sent as a fax, email, or a photocopy presented in person with appropriate identification from the above agency’s staff to the record holder.*
- RELEASE OF INFORMATION FOR EMPLOYMENT (INITIALS REQUIRED): I authorize the release of my current, past, and future Employment information to the Case Manager. Such records include information related to my job title, start/end date, hourly wages, and hours worked per week.*
- ACKNOWLEDGEMENT (INITIALS REQUIRED): 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 activities and may be considered justification for dismissal if discovered later. I acknowledge that my Personally Identifying Information (PII) will be used for grant purposes only. My authorization for Release of Information to AND/OR from the agencies/organizations listed above is valid until one year after case closure from the program.*
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- Applicant Signature*
- Date*
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- Parent/Guardian Signature (If applicant is under the age of 18)*
- Date*
- Complaint Procedures, Equal Opportunity Law, & Babel Notice
- Complaint Procedures, Equal Opportunity Law, & Babel Notice Acknowledgement
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- Should be Empty: