WIOA - CareerSource Pasco Hernando Pre-Eligibility Application

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

First NameMiddle NameLast Name
County of Residence
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
Format: (000) 000-0000.
Type of Phone Number - Primary
Alternative Phone Number
Format: (000) 000-0000.
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:

Other
Public Assistance - Select all benefits that you have applied for, receiving, or exhausted:

Other
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
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)
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?
If yes, please indicate your discharge date:

MonthDayYear
Date
Eligible Veteran Status (If yes, please provide a copy of your DD 214 form)
Are you the spouse of a member of the armed forces who is on active duty?
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)
Have you worked as a farmworker in the last 12 months?
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?
Are you an offender?
Basic Skills Deficient/ Low Levels of Literacy?
Do you consider yourself to have a disability?
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:
School/ Training Information
Are you currently enrolled in school?
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?
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?
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?
Do/ Did you receive Benefits
Are you under-Employed?
Have you received a notice of laid off letter or a termination letter?
Are you considered to be Long-Term Unemployed (27 or more consecutive weeks)?
If no longer working, reason for separation
Type of income? (Check all that apply)
Do you currently have a resume?
Upload your most up to date resume

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General Information
Ticket-to-Work Holder issued by Social Sec. Admin
Are you in a Registered Apprenticeship Program?
Are you a English Language Learner?
Do you meet Governors Special Barriers to employment?
Do you currently reside in a homeless shelter or are you currently homeless?
Is your housing situation stable?
Are you a single Parent
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?
Are you currently in foster care or aged out of foster care?
Do you have reliable transportation to attend your worksite?
What is your method of transportation? (select one or more of the following)
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
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.
(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.
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.
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.
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.
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 certify that I have received a copy of and understand my rights and responsibilities as enumerated in this statement.
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.
Eligibility Documentation - Upload
Please upload clear photos or scans. Each file must be 15 MB or smaller. Accepted formats: PDF, JPG, or PNG.
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?
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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Training Program Documentation (Required for Training Requests)

If you are requesting training assistance, please upload the documents below. These documents help us review your training request and determine funding eligibility. If you do not have a document available, you may still submit your application and a staff member will follow up.

Please upload clear photos or scans. Each file must be 15 MB or smaller. Accepted formats: PDF, JPG, or PNG.
Training Program Details and Cost Information

Accepted Documents: Training provider cost sheet, Enrollment agreement, and/or Program brochure with pricing
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Acceptance or Conditional Acceptance Letter

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Financial Aid Award Information (if applicable)

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Unofficial Transcripts or Most Recent Report Card

Accepted Documents: Unofficial college transcripts, High school transcripts, Most recent report card, and/or GED scores
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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

Training Program Documentation (Required for Training Requests)