WIOA Eligibility Form

WIOA Eligibility Form

All answers are confidential and used to determine eligibility status for tuition assistance.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your age? *
How were you referred?*
If you chose "Other" please list below:
Are you interested in training?*

YesNo
If interested in training, what is your desired educational goal?
If interested in training, what educational institution would you like to attend?
Are you interested in job search and resume preparation assistance?*

YesNo
Are you interested in a paid work experience?*

YesNo
Are you interested in employability workshops?*

YesNo
Are you currently working?*

YesNo
Do you receive public assistance? (TANF, KTAP, SSI, SNAP)*

YesNo
Are you a high school dropout and earning a GED?*

YesNo
Are you pregnant or parenting?*

YesNo
Do you have a disability?*

YesNo
Are you homeless? (No permanent residence)*

YesNo
Are you over the age of 55?*

YesNo
Have you been unemployed for 12 consecutive weeks or more?*

YesNo
Have you been unemployed for 14 of the last 27 weeks?*

YesNo
Do you have a sporadic work history, including a history of temporary/seasonal employment, multiple terminations, or multiple quits?*

YesNo
Do you lack a work history? (i.e. Have not had a job)*

YesNo
Are you drawing unemployment?*

YesNo
Are you a displaced homemaker? (i.e. Have you been providing unpaid services to family members in the home and been dependent on the income of another family member but no longer supported by that income (due to divorce, spouse laid off, spouse filed for disability)*

YesNo
Are you the spouse of a member of the Armed Forces on active duty and who has experienced a loss of employment as a direct result of relocation to accommodate a permanent change in duty station?*

YesNo
Have you had a misdemeanor or felony?*

YesNo
What is your approximate income in the past six months?*
Should be Empty: