QUEST DISLOCATED WORKER TRAINING APPLICATION

WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) DISLOCATED WORKER TRAINING APPLICATION

QUEST RELATED
You MUST reside in one of these counties, or you must have been laid off from a job in one of these counties, to receive services through Worksource Northwest Georgia.*

BartowCatoosaChattoogaDadeFanninFloydGilmerGordonHaralsonMurrayPauldingPickensPolkWalkerWhitfield
I am interested in:

Transitional JobsTraining
Date

MonthDayYear
Today's date
Full Name
Social Security # (Last 4 Digits)
ONLY the last four digits
Address

Street address

Street Address Line 2

CityState

Zip Code
Mailing address
If different from above
City
State
Zip Code
Home Phone
Cell Phone
Email
example@example.com
The person listed below does not live with me but can always contact me.
Name
Relationship
Telephone
Demographic Information
Race (check all that apply)

African American/BlackAmerican Indian or Alaskan NativeAsianHawaiian or Pacific IslanderCaucasian or WhiteOther
Ethnicity

Hispanic Heritage
Gender

FemaleMale
Date of birth*

MonthDayYear
MM/DD/YYYY
U.S. Citizen or Naturalized:

YesNo
If yes, list alien registration number
Alien Registration #
Date

MonthDayYear
alien registration date
If no, authorized to work in US?

YesNo
Disability Status

YesNoPrefer Not to Answer
Selective Service Compliance:

YesNoN/A
Driver’s License/State ID Information
Do you have a State Driver's License?

YesNo
Driver’s License Type

RegularCommercial (CDL)CDL Endorsements
Class

ABCOther
Do you have a State ID?

YesNo
Has your license ever been or/is currently Suspended or Revoked?

YesNo
Education History
Highest Grade Completed
Highest Credential Earned:

HSD/GEDCertificateAssociatesBachelorsMastersPhDNone
List degrees/certificates area(s) of study
Currently in School?

YesNo
If yes, Name of School
School you are currently enrolled in
If yes, Name of Program
Program you are currently enrolled in
If yes, Anticipated completion date

MonthDayYear
Date
List any current professional license(s) you hold
Veterans and Qualified Spouses Information
Veteran

VeteranNot a VeteranQualified Spouse of a VeteranTransitioning Service MemberActive Duty
* Active duty includes full-time Federal service in the National Guard or a Reserve component. This does not include full-time duty performed strictly for training purposes (i.e., “weekend” or “annual” training), nor does it include full0time active duty performed by National Guard personnel who are mobilized by State rather than Federal authorities (State mobilizations usual occur in response to events such as natural disasters.
Information in this section applies to Veterans only
Branch of Service

Air ForceArmyCoast GuardNavyU.S. Marines
Nature of Military Discharge

HonorableDishonorableLess than HonorableService Connected Disability
Dates of Service

MonthDayYear
Begin
Dates of Service

MonthDayYear
End
Service Connected Disability

NoDisabled VetSpecial Disabled Vet
Armed Forces Campaign or Expeditionary Medal:

YesNo
Served More than One Tour of Duty:

YesNo
Recently Separated: (within 48 months)

YesNo
A BRAC-impacted Worker:

YesNo (BRAC may be considered eligible as Dislocated Worker)
Employment Information
Have been temporarily or permanently laid off because of the COVID-19 pandemic disaster

Temporary LayoffPermanent Layoff
Separation Date

MonthDayYear
Check all that apply

Have been unemployed 12 of the last 15 weeks.Long-term individual with barriers to employment, such as veterans, ex-offender, etc., andA self-employed individual who became unemployed or significantly under employed because of the COVID 19 pandemic disaster and have been unemployed for the most recent 4-week periodCurrently receiving or have received Unemployment compensation in the last 12 months.
Employment History
List current and previous employers of last 3 jobs, beginning with current or most recent job.
Most recent employer
Employer Name
Job Title
Most recent employer
Address
Most recent employer
Phone
Most recent employer
Hourly Wage
Most recent employer
Hours per week
Most recent employer
Shift
Most recent employer
Main Duties
Most recent employer
Equipment Used
Most recent employer
Start Date

MonthDayYear
Most recent employer
End Date

MonthDayYear
Most recent employer
Reason for Leaving:

Laid offQuitTerminatedOther employmentPlant closureOther
Previous employer
Name of Employer
Job Title
Previous employer
Address
Previous employer
Phone
Previous employer
Hourly Wage
Previous employer
Hours per week
Previous employer
Shift
Previous employer
Main Duties
Previous employer
Equipment Used
Previous employer
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Reason for Leaving:

Laid offQuitTerminatedOther employmentPlant closureOther
Previous employer
Employer Name
Job Title
Most recent employer
Address
Most recent employer
Phone
Most recent employer
Hourly Wage
Most recent employer
Hours per week
Most recent employer
Shift
Most recent employer
Main Duties
Most recent employer
Equipment Used
Most recent employer
Start Date

MonthDayYear
Most recent employer
End Date

MonthDayYear
Most recent employer
Reason for Leaving:

Laid offQuitTerminatedOther employmentPlant closureOther
WIOA RELEASE OF INFORMATION CONSENT/CERTIFICATION AND ACKNOWLEDGEMENT
RELEASE INFORMATION FOR ELIGIBILITY INITIAL HERE*
I authorize the release of my information to the Career Advisor as necessary to determine my eligibility for the Workforce Innovation and Opportunity Act (WIOA) Dislocated Worker programs and 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 (DFACS), and the Department of Labor (DOL 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 a confidential and responsible manner.
RELEASE INFORMATION FOR EMPLOYMENT INITIAL HERE*
I authorize the release of my past, current, and future employment information to the Career Advisor. Such records include information related to my employer’s name, job title, start/end date, hourly wages and hours worked per week.
PHOTOGRAPH RELEASE
I hereby authorize the Workforce Innovation and Opportunity program in Northwest Georgia including the WIOA staff of The Northwest Georgia Regional Commission and its contracted WIOA program service providers to use my photograph or video image in conjunction with my name (or fictitious name) for sale of or reproduction in any medium for the purpose of advertising, display, audiovisual exhibition or editorial use.
INITIAL HERE*
I authorize that my picture can be taken (check one):*

YESNO
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 and activities and may be considered justification for dismissal if discovered at a later date. I acknowledge that my Personal Identifying Information (PII) will be used for grant purposes only. I acknowledge that I have been informed of all available WIOA training activities in this area.

I understand that my eligibility for WIOA and/or referral to a WIOA training Contractor DOES NOT mean that I have been automatically accepted into that Contractor’s training program.

I acknowledge that in accordance with Section 680.210 of the Federal Register and WIOA Section 134(c3A), of the ACT, WIOA is not an entitlement program.

Applicants are responsible for ensuring that ALL required documentation is attached to their application

Missing documentation will delay the process of your application.
CERTIFICATION AND ACKNOWLEDGEMENT INITIAL HERE*
Are you related by blood, marriage, or adoption to anyone on staff of the Service Provider, TCSG, Local Workforce Development Area, Sub-State Grantee, Georgia Department of Labor, or Field Service Office?*

YesNo
Are you related by blood, marriage, or adoption to anyone on staff of the Service Provider, TCSG, Local Workforce Development Area, Sub-State Grantee, Georgia Department of Labor, or Field Service Office? *
Initial here
Please read the above carefully, initial each release/acknowledgement, sign and date
Applicant’s Signature*
Date*

MonthDayYear
Today's date
In accordance with 29 CFR 38.9 (g3), Limited English Proficient (LEP) individuals through Northwest Georgia Worksource Georgia, will receive language assistance in all communications of vital information. Vital information is defined as information whether written, oral or electronic, that is necessary for an individual to understand how to obtain any aid, benefit, service, and/or training; necessary for an individual to obtain any aid, benefit, service, and/or training; or required by law. An interpreter, as well as the availability of free language assistance such as rulebooks; written tests that do not access English language competency, but rather assess competency for a particular license, job, or skill for which English proficiency is not required; and letters or notices that require a response from the beneficiary or applicant, participant, or employee will be provided to all LEP individuals at no cost to the individual. (29 CFR § 38.4(ttt)

TO ACCESS AN INTERPRETER CALL NORTHWEST GEORGIA REGIONAL COMMISSION WIOA DEPARTMENT AT 706.295.6485

An Equal Opportunity Employer/Program. Auxiliary Aids and Services Upon Request to Individuals with Disabilities TTY/TDD 1.800.255.0056
Should be Empty:

WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) DISLOCATED WORKER TRAINING APPLICATION

Demographic Information

Driver’s License/State ID Information

Education History

Veterans and Qualified Spouses Information

Information in this section applies to Veterans only

Employment Information

Employment History

WIOA RELEASE OF INFORMATION CONSENT/CERTIFICATION AND ACKNOWLEDGEMENT

PHOTOGRAPH RELEASE