WIOA Intake Form

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Phone Number*

Area CodePhone Number
Email*
Sex*
SSN*
Birthdate*

MonthDayYear
Date
Age*
Race*

American IndianWhiteBlackHispanicAsianOther
Tribe*
Tribal Enrollment Number
Marital Status*
Education at Enrollment*
Educational Level*
Employment Status*
Do you have a layoff letter?

YesNoNot sure
Are you eligible for unemployment?

YesNoNot sureI have exhausted my unemployment benefits
Do any of these apply to you? (Please check all that apply)*

VeteranSpouse of a VeteranDisabledNone of the above
Do any of these apply to you? Please check all that apply.

Did you lose your previous job through no fault of your own, as a result of a downsizing, restructuring, the COVID-19 pandemic or some similar actions?Are you recently divorced or have you become a widow/widower in the last 5 years?Were you honorably released from the Military in the last 2 years (must provided DD214)?
Do any of these apply to you? Please check all that apply

You are receiving public assistanceYou have a disabilityYou been subject to any stage of the criminal justice process (felony, misdemeanor, arrest record, diversion, deferral)?You have a belief or practice that would restrict you from some employment opportunities?You are a single parent of a child under the age of 18You are 55 or olderYou are low income, which includes being homeless, a foster care youth, and a recipient of free or reduced lunch (including parents)?
Are you or a member of your family currently receiving or received in the last 6 months any of the following types of assistance? Please check all that apply.

SSISSDIFood Stamps/SNAPLEAPTANF/Colorado WorksCCAPRefugee AssistanceSection 8
Employment History
Employment History
Signature
Date*

MonthDayYear
Date
Please verify that you are human*
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