WIOA Eligibility Survey
Name
First Name
Last Name
Best Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Parish of Residency
Please Select
Terrebonne
Lafourche
Assumption
Do any of these apply to you? Please check all that apply.
Did you or a spouse lose a 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)?
Are you a spouse of an active military member that was relocated to Louisiana (Change of Duty)?
Do any of these apply to you? Please check all that apply.
You or a family member is receiving public assistance, or has received public assistance in the last 6 months.
You have a disability.
You have 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 do NOT have a high school diploma or GED.
You are a single parent of a child under the age of 18.
You are 55 or older.
You are low income individual, which includes being homeless, a foster care youth, and a recipient of free or reduced lunch (including parents)?
Are you currently enrolled in a post secondary school or training program?
Yes
No
What are you hoping to get out of the WIOA Program? Please be as specific as possible.
Submit
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