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
MaleFemale
Last 4 digits of your Social Security Number*
CHOOSE ONLY ONE OPTION FROM THE TWO PROMPTS BELOW
YesNo
YesNo
Card Expiration Date*

MonthDayYear
Employed Full-TimeEmployed Part-TimeUnemployed (actively seeking employment)Not in the Workforce
UC ClaimantExhaustedNot Applicable
YesNoNot Disclosed
YesNo
American Indian/Alaskan NativeNative Hawaiian/Pacific IslanderInformation Not ProvidedAsianWhiteBlack/African American
VETERAN/SELECTIVE SERVICE INFORMATION
YesNo
YesNoNot Required
EDUCATION INFORMATION
YesNo
Name of School Attending*
YesNo
Highest Grade Completed*
HS DiplomaGEDCertificationAssociatesBachelorsMasters
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)
YesNo
TANF-Monthly Amount*
YesNo
SNAP-Monthly Amount*
YesNo
SSI-Monthly Amount*
YesNo
GA-Monthly Amount*
YesNo
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.
SingleMarried coupleMarried couple and dependent childrenIndividual with a disabilityParent or guardian and dependent children
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
Displaced HomemakerEx OffenderEnglish Language LearnerParenting/Pregnant YouthSingle ParentFoster CareHomelessLong Term Unemployed (27 or more consecutive weeks)
YesNo
Full-TimePart-TimeEither
On-site onlyRemote onlyHybrid (in-person and remote)No preference/Open to all
EMPLOYMENT INFORMATION
CURRENT OR MOST RECENT EMPLOYMENT
Employer Name*
Job Title*
Start Date*

MonthDayYear
End Date

MonthDayYear
Hourly Wage*
Terminated/FiredQuitStill EmployedLayoffRetiredOther
PREVIOUS EMPLOYMENT
Employer Name
Job Title
Start Date

MonthDayYear
End Date

MonthDayYear
Hourly Wage
Terminated/FiredQuitStill EmployedLayoffRetiredOther
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