WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA)

Contact Information The person whose name is listed below does not live with me but can always contact me.

Race (check all that apply):

Public Assistance (If Yes, Provide Verified Documentation)

Individual or family member receiving or in the past six months received one of the following

*Qualified Spouse is a spouse of -

• a veteran on active duty and whose family income is significantly reduced because of deployment, a call to active duty, a permanent change of station, and is unemployed or underemployed and is experiencing difficulty in obtaining or upgradingemployment; or
• a veteran who died of a service-connected disability; or
• a member of the Armed Forces who is listed in one of the following categories for at least 90 days:

          -missing in action,
          -captured in the line of duty,
          -forcibly detained by a foreign government; or
          -a veteran who died while a disability was in               
            existence.

**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 full-time 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).

If yes, Name of School, Program, Anticipated completion date List the name of schools you have attended, including high school. List any degrees/certificates and areas of study.

*Underemployed-employed less than full-time and seeking full-time employment; or those employed in a position not commensurate with the individual's level of education; or working full-time and meet the definition of low income; or those employed but current job earnings are not sufficient compared to their previous earnings.

RELEASE INFORMATION FOR ELIGIBILITY

I authorize the release of my information to the Career Advisor, including the WIOA staff of the Northwest Georgia Regional Commission, as necessary to determine my eligibility for the Workforce Innovation and Opportunity Act (WIOA) Adult and Dislocated 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.

I authorize the release of my current, past, and future educational records from high school, colleges, universities and training schools to the Career Advisor, including the WIOA staff of the Northwest Georgia Regional Commission. Such records include my current/past/future enrollment, transcripts, attendance records, graduation/completion information and any/all credential(s) attained. I understand that under the Family Educational Rights and Privacy Act of 1974 (FERPA), which is a Federal law that protects the privacy of student education records that the Career Advisor must have my written consent to obtain my educational records. I certify that this authorization of release form may be sent as a fax, email, or a photocopy presented in person with appropriate identification from the above agency's staff to the record holder.

PHOTOGRAPH RELEASE

I hereby authorize the Workforce Innovation and Opportunity Act 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 I any medium for the purpose of advertising, display, audiovisual exhibition or editorial use.

I authorize the release of my past, current and future employment information to its contracted WIOA program service providers or WIOA staff of the Northwest Georgia Regional Commission. Such records include information related to my employer's name, job title, start/end date, hourly wages and hours worked per week.

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. I acknowledge that I will stay in contact with the Career Advisor for one year after I complete and exit the program for follow-up purposes. Applicants are responsible for ensuring that ALL required documentation is attached to their application Missing documentation will delay the process of your application.

Please read the above carefully, initial each release/acknowledgement, sign and 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. Aninterpreter, 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