WORKER ADVANCEMENT INITIATIVE APPLICATION FORM

Are You a Member of the Abacor LLC Team or an Authorized Entity?

YesNo
Name of Person Completing this Form

First NameLast Name
Email Address of the Person Completing this Form
example@example.com

WORKER ADVANCEMENT INITIATIVE APPLICATION FORM
You have been provided this application packet based on your inquiry into services related to employment and/or education. Completion of an application does not guarantee eligibility and/or receipt of specific services. The determination of appropriate services will be made by Bay Area Workforce Development Board (Bay Area WDB) staff after the eligibility process is completed.

Please note:
- The information provided on this application will not be used to discriminate or eliminate you from potential participation in the Worker Advancement Initiative (WAI) Program – WAI is an equal opportunity program.
- No information provided on this application will be shared with any other agency or organization without your expressed written consent.
INITIAL PROGRAM ELIGIBILITY
INFORMATION REGARDING THE REQUEST FOR YOUR SOCIAL SECURITY NUMBER
NOTE: The Code of Federal Regulations, Title 20, Section 677.175 authorizes this program to request your social security number (SSN We use your SSN to collect employment and educational outcome information for federal reporting. Your SSN will be used only for this purpose. The state and federal governments use outcome information to evaluate how to best help future program participants. It is your right to choose not to provide your SSN. If you do not provide your SSN, it will not have any effect on the services you are eligible to receive. Because the program will not be able to use your SSN to collect employment and educational outcome information for federal reporting, you agree to tell staff who contact you after you exit the program if you are employed and how much you are earning.

The following information must be verified to determine eligibility for Workforce Advancement Initiative Services. Required documents must be provided for verification purposes. The list of required documents can be found following the I-9 link.

If individual is verified to be eligible to work in the United States, the full application must be completed and submitted for approval to Bay Area Workforce Development Board (at Requests@bayareawdb.org) prior to provision of WAI services.
Applicant Name
Applicant Asset PIN
Internal Use Only
I-9 List A Document
Document Title
Document Number
Expiration Date (if applicable)

MonthDayYear
Date
I-9 List B Document
Document Title
Document Number
Expiration Date (if applicable)

MonthDayYear
Date
I-9 List C Document
Document Title:
Document Number
Expiration Date (if applicable)

MonthDayYear
Date
U.S. Citizen

YesNo
Eligible to Work in the U.S.

YesNo
I attest I have verified the above eligibility documents provided by the applicant.
Program Provider Signature

Clear
Date

MonthDayYear
Date
Bay Area WDB, serving WIOA Title I, is an Equal Opportunity Service Provider and Employer.
This program is made available by a grant from the American Rescue Plan Act Coronavirus State and Local Fiscal Recovery Funds. Bay Area WDB is an equal opportunity employer and service provider. If you have a disability and need assistance with this information, please dial 7-1-1 for Wisconsin Relay Service. Please contact 920-617-1384 or info@bayareawdb.org to request free of charge information in an alternate format, including a translation to your preferred language.

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WORKER ADVANCEMENT INITIATIVE APPLICATION FORM

INITIAL PROGRAM ELIGIBILITY

INFORMATION REGARDING THE REQUEST FOR YOUR SOCIAL SECURITY NUMBER

Internal Use Only

WORKER ADVANCEMENT INITIATIVE APPLICATION FORM

Applicant's Gross Income Information

Applicant's Household Member Past 6 Months Gross Income Information

WDB Use Only