Cumberland/Sampson WIOA Interest Form

WIOA Interest Form

Please complete if you are interested in the NextGen or Adult Program.
YesNo
STOP. Go to www.ncworks.gov and create an account. Then continue with this form.
NCWorks Username:*
- Name*
  
  First NameLast Name
- E-mail*
  example@example.com
- Phone Number*
  Format: (000) 000-0000.
- Preferred method of contact:*
- Age*
- County:*
- Zip Code*
- Please be as accurate as possible when selecting those that apply to you. This will not hinder your eligibility, it will allow us to assist you as best as possible.
- Low IncomeUnder the age of 18Dropped out of schoolCurrently enrolled in a GED programEnglish Language LearnerCurrently homeless, couch surfing, or a runawayCurrently pregnantParent to a childIn foster care or aged out of the foster care systemIs or has ever been justice involvedHas a disability or has had a 504 or IEP in schoolHas been expelled or suspended within the last 12 monthsHas experienced substance abuseVeteran or Military SpouseNone of the above
- Veteran or Military SpouseLow IncomeBasic Skills DeficientOver the age of 18Has experienced substance abuseHas been justice impactedHas been out of work for 27 weeks or longerDisplaced HomemakerNone of the above
- What occupation/career field are you interested in?*
- YesNo
- Current Employment Status*
- I have a work historyI have never legally worked before
- Last Date of Employment *
  
  MonthDayYear
  Date
- YesNo
- Please select your highest level of education completed*
- YesNo
- High SchoolAlternate High SchoolVocational or Technical SchoolCommunity College4 year College/UniversityOther
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- Current Family Size*
  Number of people living in your household who are related by blood, marriage, or decree of court. Please include yourself.
- What is your annual income (within the last 12 months)*
  Please include income of all members included in family size. If none or unsure, put $0.00.
- Tuition AssistancePaid InternshipCareer ExplorationJob ShadowingJob Search AssistanceOn-the-Job TrainingFull-time employmentPart-time employmentPost-secondary Education/Training PreparationEducational/Employment Readiness ActivitiesLabor Market InformationFinancial LiteracyOther
- Job Search AssistanceTuition AssistanceOn-the-Job TrainingVocational AssessmentsLabor Market InformationEducational/Employment Readiness ActivitiesOther
- If there is a school you are interested in, please list them here.
- Estimated Start Date:
- YesNo
- If yes, please select who you spoke with*
- How did you hear about this program? *
- An Affirmative Action and Equal Opportunity Employer/Program.
  
  Auxiliary aids and services are available upon request to individuals with disabilities.
  
  The Stevens Amendment - www.mccog.org - https://mccog.org/the-stevens-amendment.asp
  
  By submitting this form I certify that the information on this document is true to my knowledge and belief. I understand that such information is subject to verification and further understand that the above information, if misrepresented or incomplete, may be grounds for immediate termination of any WIOA program and/or penalties as specified by law. Submission of this form does not guarantee enrollment into a WIOA program. An advisor will contact you soon.
- Should be Empty:

WIOA Interest Form

Please be as accurate as possible when selecting those that apply to you. This will not hinder your eligibility, it will allow us to assist you as best as possible.