WIOA Pre-Application

WORKFORCE INNOVATION AND OPPORTUNITY ACT TRAINING PRE-APPLICATION
Choose a Job Training Unlimited, WIOA staff
Applicant Name*

First NameLast Name
Physical Address*

Residential Street Address

Street Address Line 2

CityState

Zip
County*
County your residential address is located in
Mailing Address

Mailing Address: (if different from above)

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone*
Other Phone
Primary Email*
example@example.com
Preferred Contact Method*

CallTextEmailInternal Message (GWR)
Best Day to Contact You*

MondayTuesdayWednesdayThursdayFriday
Best Time to Contact You*

AMPM
Do you have a Social Media Account? Facebook, Instagram, Twitter, etc*

YesNo
Name of Social Media Site
(Facebook, Instagram, etc.)
Profile Name
Please list an alternate contact for yourself. This should be someone who does NOT live with you but can always contact you.
Contact Name*
Relationship to you*
(Parent, Sibling, Neighbor, etc.)
Contact Address

Address

Street Address Line 2

CityState

Zip
Contact Home Phone
Contact Cell Phone*
Contact Primary Email
example@example.com
Applicant Date of Birth*

MonthDayYear
Date
Applicant Current Age*
Ethinicity*

African American/BlackAmerican Indian/Alaskan NativeAsian American/AsianHispanic HeritageHawaiian/Pacific IslanderCaucasian/WhiteI do not wish to answerOther
Gender*

MaleFemale
Citizenship*

U.S. Citizen or NaturalizedU.S. Permanent ResidentAlien/Refugee Lawfully Admitted
Alien Registration Number
Expiration Date

MonthDayYear
Date
Are you registered with Selective Service? (Males ONLY, born ON or AFTER 1/1/1960)*

YesNoNot Applicable
Are you pregnant/parenting?*

YesNo
Are you homeless?*

YesNo
Are you a runaway?*

YesNo
Do you consider yourself to have a disability?*

YesNo
Do you speak English?*

YesNo
Primary Language if other than English
Have you ever been convicted of a criminal offense?

YesNo
Highest Credential Earned*

NoneHigh School Diploma/GEDCertificate/CredentialBachelor's DegreeAssociate Degree
Highest Grade Completed*

8th9th10th11th12thSome CollegeOther
Are you currently in school?*

YesNo
Specify

High SchoolGED/Adult EducationCollege/Technical School
Name of School
Program of Study
Anticipated Graduation (Month/Year)
Employment Status*

Working Full TimeWorking Part TimeNot EmployedNever Worked
Last Date of Employment

MonthDayYear
Date
Employment History (Type of business worked in)

Private BusinessLocal GovernmentState GovernmentFederal GovernmentEducation (K-12)Non-Profit Higher EducationOther:Other
Are you currently looking for work?*

YesNo
Desired job Title
Have you worked on a farm or as a migrant/food processor as least 25 days in the past 12 months?*

YesNo
Have you been laid off or are you unable to find work due to the COVID-19 Pandemic?*

YesNo
Are you receiving Unemployment Insurance?*

Yes, currently receivingYes, exhausted benefitsNo, neither claimant nor exhaustee
Within the last 12 months, have you received a notice of termination or layoff from your job?*

YesNo
Within the last 12 months, have you received documentation that you are separating from military service?*

YesNo
If terminated, laid off, received notice of termination or layoff or military separation enter last date of employment

MonthDayYear
Date
Have you been supported through the State's Foster Care System? (State or local payments are made for applicant)*

YesNo
Have you received Refugee Cash Assistance Payments (RCA)?*

YesNo

Do you OR does anyone in your household currently receive, or in the past 6 months have received ANY of the following? *

	Yes, Applicant	Yes, Family Member	None
Cash Welfare Payments (TANF)
Food Stamps (SNAP)
General Assistance (GA) (Medicaid, PeachCare, Amerigroup, etc.)
Supplemental Security Income (SSI)
Supplemental Security Disability Insurance (SSDI)

Family Size*
*Include ONLY: Guardians, Parents, Spouse, Siblings, Children or Dependents that live with you
Household Income
Specify frequency of Household Income

WeeklyMonthlyAnnually
Are you currently in the military, a Veteran, or the spouse of a Veteran?*

YesNo
Are you within 24 months of retirement OR 12 months of discharge from the military?*

YesNo
Planned retirement/discharge date

MonthDayYear
Date
Have you served on Active Duty in the armed forces and were discharged or released from service under conditions other than dishonorable?*

YesNo
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?*

YesNo
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?*

YesNo
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?*

YesNo
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.*
Applicant Name*
Applicant Signature*
Date*

MonthDayYear
Date
Parent/Guardian Name (If applicant is under the age of 18)*
Parent/Guardian Signature (If applicant is under the age of 18)*
Date*

MonthDayYear
Date
Complaint Procedures, Equal Opportunity Law, & Babel Notice
Complaint Procedures, Equal Opportunity Law, & Babel Notice Acknowledgement
Should be Empty:

WORKFORCE INNOVATION AND OPPORTUNITY ACT TRAINING PRE-APPLICATION