WIOA Preliminary Intake Application (2026)

Sender
WIOA May Have Funds Available
If you answer YES to one or more of the following, contact us at 919-988-6871 or 919-988-6872.
- Are you unemployed or underemployed?
- Have you been laid off from your job?
- Are you receiving public assistance?
- Do you need assistance with career development?
- Do you need assistance with job search, resume writing, interview procedures, and/or dressing for success?
Must have the following:
- US Citizen or Legal Alien
- Birth certificate or documentation
- Social Security Card
- NC Photo ID or Driver’s License
- Selective Service Registration (males only)
- Dislocated workers need:
  - Notice of layoff or no-fault termination
  - Verification of unemployment insurance status
  - Job search record
APPLICANT INFORMATION
Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
DEMOGRAPHICS
Intake Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Gender
Last 4 digits of your Social Security Number
CHOOSE ONLY ONE OPTION FROM THE TWO PROMPTS BELOW
U.S. Citizen or Legally Entitled to Work in the U.S.
Eligible Non-Citizen
Card Expiration Date

MonthDayYear
Current Employment Status
Unemployment Compensation (UC) Eligible Status
Individual with Disability
Ethnicity (Hispanic or Latino)
Race (more than one race can be checked)
VETERAN/SELECTIVE SERVICE INFORMATION
Served in the U.S. Military
Registered with Selective Service (Males 18 or older, born on or after Jan. 1, 1960)
EDUCATION INFORMATION
Currently Attending School
Name of School Attending
Dropped out of High School
Highest Grade Completed
Highest Level of Education (Check only if attained)
Associates Degree - Date Attained (Month/Year)
Bachelors Degree - Date Attained (Month/Year)
Masters Degree - Date Attained (Month/Year)
Type of Certification
PUBLIC ASSISTANCE

(Are you currently or within the last 6 months received any of the following?) (Check all that apply)
TANF-Temporary Assistance for Needy Families
TANF-Monthly Amount
SNAP-Supplemental Nutrition Asst. Program
SNAP-Monthly Amount
SSI-Supplemental Security Income
SSI-Monthly Amount
GA-General Assistance
GA-Monthly Amount
RCA-Refugee Cash Assistance
RCA-Monthly Amount
FAMILY SIZE/FAMILY INCOME
Definition of Family under WIOA: Means two or more individuals related by blood, marriage, or decree of court, who are living in a single residence, and are included in one of the following categories.
Family Type
Income Received From

EXAMPLE: If the intake Date is 7/2/2025, include gross income received from December 29, 2024 through June 28, 2025 for the entire six-month period.
Beginning Date:

MonthDayYear
Ending Date:

MonthDayYear

Total Gross Amount From Family Members
INDIVIDUAL/EMPLOYMENT BARRIERS
Type of barrier (select all that apply)
Are you able to work?
If yes, indicate preference
What is your preferred work environment?
EMPLOYMENT INFORMATION
CURRENT OR MOST RECENT EMPLOYMENT
Employer Name
Job Title
Start Date

MonthDayYear
End Date

MonthDayYear
Hourly Wage
Reason for Leaving

Other
PREVIOUS EMPLOYMENT
Employer Name
Job Title
Start Date

MonthDayYear
End Date

MonthDayYear
Hourly Wage
Reason for Leaving

Other
Should be Empty:

Rows	Family Member Name	Relationship to applicant	Age	Income Source (employment, retirement, gifts, etc.)	Total Gross Amount received during last 6 months
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WIOA May Have Funds Available

APPLICANT INFORMATION

DEMOGRAPHICS

CHOOSE ONLY ONE OPTION FROM THE TWO PROMPTS BELOW

VETERAN/SELECTIVE SERVICE INFORMATION

EDUCATION INFORMATION

PUBLIC ASSISTANCE

FAMILY SIZE/FAMILY INCOME

Income Received From

INDIVIDUAL/EMPLOYMENT BARRIERS

EMPLOYMENT INFORMATION

CURRENT OR MOST RECENT EMPLOYMENT

PREVIOUS EMPLOYMENT