CareerSource Pasco Hernando Pre-Eligibility Application

CareerSource Pasco Hernando Pre- Eligibility Application
Customer Details:
Full Name*

First NameMiddle NameLast Name
County of Residence*

HernandoPascoOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address different than your street address?*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Type of Phone Number - Primary*
Alternative Phone Number*
Type of Phone Number - Alternative*
Personal E-mail*
example@example.com
How did you hear about our program? Please specify the organization or source that referred you.*
Eligibility Screening Questions
Public Assistance - Select all benefits that you have applied for, receiving, or exhausted:

Unemployment Benefits (Reemployment)SNAP/ Food BenefitsTANF/ Cash Assistance BenefitsLow Income HouseholdN/AOther
Public Assistance - Select all benefits that you have applied for, receiving, or exhausted:*

Unemployment Benefits (Reemployment)SNAP/ Food BenefitsTANF/ Cash Assistance BenefitsLow Income HouseholdN/AOther
SNAP Receipt Type*
TANF Receipt Type*
Have you received SNAP benefits within the last 6 months?*
Have you received TANF benefits within the last 6 months?*
Are you receiving Reemployment Assistance (Unemployment Benefits), Exhausted Unemployment Benefits or received a Notice or Letter of Lay Off?*
Your Unemployment Eligibility Status*

ClaimantExhaustedNeither Claimant or Exhauste
Annualized Family Income*
(Family income = all those living in a household related by blood, marriage or court decree) Annualized Income Definition:Annualized income refers to an estimate of a person's total income over a full year, based on earnings from a shorter period. For example, if someone earns $10,000 in three months, their annualized income would be projected as $40,000 for the year (assuming the same earnings rate continues).
Do you meet our family income guidelines for WIOA training services? (Refer to the chart above)*

YesNo
Please choose which family size applies:*
This includes the total number of people in your family = all individuals in your household related by blood, marriage or court decree)
Selective Service Registration (for males 18yrs or older)*
All males born January 1, 1960 or later are required to register with Selective Service. visit www.sss.gov for more information.
Veteran Information
Are you a Transitioning Service Member?*

Yes, within 24 months of retirementYes, within 12 months of dischargeNo
If yes, please indicate your discharge date:*

MonthDayYear
Date
Eligible Veteran Status (If yes, please provide a copy of your DD 214 form)*

Not ApplicableYes, Eligible VeteranYes, under 180 daysNo
Are you the spouse of a member of the armed forces who is on active duty?*

YesNo
Potential Program Eligibility Determination
Based on your responses to Eligibility Screening questions you may be eligible under the WIOA Dislocated Worker Program.

Please upload the following Required Documents:
- Valid State ID or Driver’s License
- Social Security Card
- Proof of Unemployment benefits Claimants and Exhausted benefits
- Self-Employment (loss of business and able to show proof of connection to the workforce, recent tax return)
- Letter of Layoff or Notice of Layoff
Based on your responses to Eligibility Screening questions you may be eligible under the Adult WIOA Program.

Please upload the following Required Documents:
- Valid State ID or Driver’s License
- Social Security Card
- Birth Certificate
- Individuals and Families that meet income eligibility guidelines- paystubs (last 26 weeks) or recent tax return.
Based on your responses, you may not qualify for this program, but you could be eligible for other services.

Please upload the following Required Documents:
- Valid State ID or Driver’s License
- Social Security Card
Demographic Information
U.S. Citizenship Status*
If Permanent Resident/ Alien Resident/ Refugee, please provide:
Alien Registration number:
Expiration date:
Last 4 of your Social Security Number*
Date of Birth*

MonthDayYear
Date
Gender*
Ethnicity*
Race (Check all that apply)*

African American/ BlackAmerican Indian/ Alaskan NativeAsianHawaiian/ Other Pacific IslanderWhiteOtherDo not wish to answer
Have you worked as a farmworker in the last 12 months?*

YesNo
Have you experienced any financial, employment, or personal hardships as a result of the COVID-19 pandemic, such as job loss, reduced work hours, increased caregiving responsibilities, or other related challenges?*

YesNo
Are you an offender?*

YesNo
Basic Skills Deficient/ Low Levels of Literacy?*

YesNo
Do you consider yourself to have a disability?*

YesNo
If yes to Considered to have a disability, the WIOA program must have within Employ Florida the documentation of verification of Disability. One of the following are allowable documentation: (Letter from drug or alcohol rehabilitation agency, Medical Records, Social Service records/referral, Physician's Statement, Psychiatrist's statement, Psychologist's diagnosis, Rehabilitation evaluation, School records, Sheltered workshop certification, Workers' Compensation record, Social Security Administration disability records, veterans Administration Letter/records, Applicant statement or Social Service Records/referral.
If yes, indicate impairment type:*

PhysicalMentalBoth
School/ Training Information
Are you currently enrolled in school?*

YesNoN/A
Which of the following best describes your current student status?*
Highest school grade completed (1st-12th grade)*
Highest education level completed*
School name you are currently attending*
Current program of training/degree*
What is the total cost of the training/degree program*
If Total Costs do not apply to you, enter “N/A” instead of leaving the field blank. This ensures accurate reporting and prevents incomplete entries. If you are unsure, please check with a representative for guidance.
As of today, what is your remaining education expense*
Describe your plan to complete the training program*
(Write an essay with a minimum of 2 paragraphs)
Planned Course of Study*
Are you receiving, or have you been notified you will receive the Pell Grant?*

YesNo
Education Partner Services
Are you receiving services from Adult Ed. (WIOA Title ll)?*
Are you receiving services from YouthBuild?*
Please provide your YouthBuild Grant number*
Are you receiving services from Job Corps?*
Are you receiving services from Voc. Education (Carl Perkins)?*
Are you receiving services from Voc. Rehabilitation?*
Employment Information
Are you currently working?*

YesNo
Current/ Most Recent Employer*

Name of Employer

City/State

Job TitleHours Per Week

Date of Hire
Date of Hire*

MonthDayYear
Date
Last Date of Employment*
Current or Most Recent Employment: Rate of Pay?*
Type of Employment*
Current or Most Recent Employment: Hourly or Annually Pay Frequency?*

HourlyAnnually
Do/ Did you receive Benefits*

YesNo
Are you under-Employed?*

YesNoN/A
Have you received a notice of laid off letter or a termination letter?*

YesNo
Are you considered to be Long-Term Unemployed (27 or more consecutive weeks)?*

YesNo
If no longer working, reason for separation*
Type of income? (Check all that apply)*

Employment Wages and SalariesNet receipts from self-employmentPension or retirement incomeRe-employment Assistance formerly called Unemployment CompensationChild SupportSocial Security BenefitsStrike benefits from Union fundsNet rental incomeAlimonyEducational assistance or training stipendsOther support from a family member/ friend not living in the householdOther income considered reportable to the IRSUnemployedVA Benefits
Do you currently have a resume?*

YesNo
Upload your most up to date resume

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General Information
Ticket-to-Work Holder issued by Social Sec. Admin*

YesNo
Are you in a Registered Apprenticeship Program?*

YesNo
Are you a English Language Learner?*

YesNo
Do you meet Governors Special Barriers to employment?*

YesNo
Do you currently reside in a homeless shelter or are you currently homeless?*

YesNo
Is your housing situation stable?*

YesNo
Are you a single Parent*

YesNo
Do you currently receive or are a member of a household family that receives Food stamps or received Food stamps during the previous six months?*

YesNo
Are you currently in foster care or aged out of foster care?*

YesNo
Do you have reliable transportation to attend your worksite?*

YesNoN/A
What is your method of transportation? (select one or more of the following)*

My own carFriends or family carBusNeed transportationOther
How the Grant May Assist You
How will this grant help you?*
(Write an essay with a minimum of 2 paragraphs)
Tell us about yourself*
(Write an essay with a minimum of 2 paragraphs)
How many credit hours are needed in your field of study?
How many credit hours have you completed?
Anticipated graduation date

MonthDayYear
Date
By checking "I Agree" box, I request and give consent for CareerSource Pasco Hernando to generate a new user account in Employ Florida to receive Wagner Peyser (WP) and/or Workforce Innovation and Opportunity (WIOA) Training Services*

I AgreeI Do Not Agree
Participant/ Employee: I certify, by my signature below, that I have read and acknowledge that the information on this form is accurate. Information is being provided to establish eligibility for training under the Workforce Innovation and Opportunity Act and is subject to all applicable Federal and State confidentiality laws.*

Powered by Jotform SignClear
(CHANGE TO SIGNATURE FIELD WHEN READY)Participant/ Employee: I certify, by my signature below, that I have read and acknowledge that the information on this form is accurate. Information is being provided to establish eligibility for training under the Workforce Innovation and Opportunity Act and is subject to all applicable Federal and State confidentiality laws.*

Yes
Release of Information
I hereby authorize all partners in the Pasco Hernando Regional Workforce Development Board’s CareerSource Pasco Hernando System to engage in verbal, written, facsimile, or computerized communication of information for the purpose of making me eligible for services or for identifying services or agencies to assist me. All pertinent records and information can be released including those regarding past, present, or future information or records that may be needed for eligibility determination, monitoring or follow-up purposes. It is my understanding that any information obtained by any partner in the CareerSource Pasco Hernando System will be held in strict confidence. I am aware that any information will be used in my best interest to provide ease of access to services.*

I authorize.I do not authorize.
Attestation
I hereby certify, to the best of my knowledge, the information provided is true. I agree and understand any willful misstatement of facts may cause forfeiture of my status in the Workforce program and could be cause for legal action. I understand the information is subject to verification and agree to provide such documentation as required. I understand my social security number may be given to other federal, state, and local government or non-government job training agencies for performance tracking purposes.*

I certify.I do not certify.
DISCRIMINATION PROCEDURES
EQUAL OPPORTUNITY IS THE LAW If you, as a Workforce Customer, feel that your rights are being violated due to an act of discrimination based on race, color, sex, national origin, religion, age, political affiliation or belief, marital status, citizenship or disability, you may file a discrimination complaint directly with CareerSource Pasco Hernando's Equal Opportunity Officer (contact information listed below), the FloridaCommerce, Office of Civil Rights, Caldwell Building, 107 East Madison Street, MSC 150, Tallahassee, FL 32399-4128, or with the US Department of Labor, Civil Rights Center, 200 Constitution Avenue Northwest, Room N-4123, Washington, DC 20210, within 180 days of the alleged occurrence.*

I have read and understand.
GRIEVANCE/COMPLAINT PROCEDURES
If you feel you have been adversely affected by a decision or action made by CareerSource Pasco Hernando, you have the right to file a written grievance/complaint to CareerSource Pasco Hernando’s Equal Opportunity Officer(contact information listed below).Information on filing a grievance/complaint can be obtained from the CareerSource Pasco Hernando’s Equal Opportunity Officer. After the opportunity for a hearing (within 60 days after formal filing), if you are dissatisfied, you may appeal to the FloridaCommerce, Office of General Counsel, Caldwell Building, Suite 150, 107 East Madison Street, Tallahassee, FL 32399-4128.*

I have read and understand.
I certify that I have received a copy of and understand my rights and responsibilities as enumerated in this statement.*

I certify.I do not certify.
GENERAL RELEASE OF INFORMATION- By acknowledging this statement, you give your permission for any Success Stories, video/audio recordings and or photographs made during this project to be used by CareerSource Pasco Hernando Workforce Board for business purposes including publications, exhibitions, World Wide Web, and presentations. By giving your permission, you give up any copy right or performance rights that you may hold.*

I agree to the uses of these materials described above.I disagree to the uses of these materials described above.
Eligibility Documentation - Upload
Please upload a copy of your Driver’s License / Photo ID

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Please upload a copy of your Social Security Card

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Please upload a copy of your Registered Selective Service, if applicable

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Please upload a copy of your DD214

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Please upload a copy of your Birth Certificate

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Do you have a copy of your paystubs (most recent or last 26 weeks) or tax return ready to upload?

Yes, I will upload my most recent paystubs (last 26 weeks) or my recent tax return.No, I need to submit an applicant statement.
Do you have a copy of your paystubs (most recent or last 26 weeks) or tax return ready to upload?
Please upload a copy of your paystubs (most recent, last 26 weeks or recent tax return)

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If Self-Employed with loss of business, please upload Tax Return.

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Should be Empty:

CareerSource Pasco Hernando Pre- Eligibility Application

Eligibility Screening Questions

Veteran Information

Potential Program Eligibility Determination

Demographic Information

School/ Training Information

Education Partner Services

Employment Information

General Information

How the Grant May Assist You

Release of Information

Attestation

DISCRIMINATION PROCEDURES

GRIEVANCE/COMPLAINT PROCEDURES

Eligibility Documentation - Upload