WIOA Youth Program Eligibility Application

Ohio Department of Job and Family Services



Applicant Name:*

 (First, MI, Last)

Mailing Address:*




Phone Number:*

Alt Phone Number:

Emergency Contact:

Contact Person's Phone Number:

Applicant Email Address*:

Date of Birth*:

Gender at Birth*:

  Male     Female    Prefer not to answer

Demographic & Education Information
1. What is your ethnicity?   Latino     Not Latino     Prefer not to answer    

2. Citizenship: (check all that apply)
 US Citizen
 Registered Alien
 Other Legal Alien

3. What is your Race? (check all that apply)
 Black/African American
 American Indian/Alaska Native
 Hawaiian Islander or Other Pacific Islander

4. Are you legally restricted from using a computer?  Yes     No

5. Relationship Disclosure - Do you have a business or personal relationship with any individual who is a:
  • Local elected official (mayor or countycommissioner);
  • Workf orce Development Board member orsubcommittee member;
  • WIOA executive, supervisor or employee;
  • OhioMeansJobs center partner employee, WIOAsub-recipient and/or contractor; or
  • County employee?
  Yes     No
If YES, provide name:

6.What is your education level?
Highest Grade Completed:
 Current high/junior high school student
 Withdrew from high school, no HS diploma
 Completed 12th grade, but no HS diploma
 Obtained certificate of equivalency for high school diploma
 High school graduate
 Some post high school education, no degree
 College Degree:    Associate    Bachelor    Masters/Prof  

7. Do you have work experience in Agriculture within the last 12 months?  Yes     No

8. What is your education status?
 I am not a student
 I am a student at a college or technical school
 I am student in HS equivalency program
 I am a high school student, at grade level
 I am a high school student, behind grade level

9. Have you served in the US Military?  Yes     No
If YES, what are your active duty dates?    to   

10. Are you a Spouse of a Veteran?  Yes     No

11. Are you a Homeless Veteran?  Yes     No

12. Do you hold a valid Driver's License?  Yes     No
If YES, Type/Class:
Non-Commercial (D)
CDL:    A;    B;    C