If you are receiving benefits,please provide your case number: Applicant Name:* (First, MI, Last) Address:* City:* State:* AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:* Phone Number:* Alt Phone Number: Additional Contact: Contact Person's Phone Number: Applicant Email Address*: Driver's License? Yes No Type: Demographic Information 1. What is your date of birth?* 2. What is your gender? Male Female 3. What is your ethnicity? Hispanic/Latino Not Hispanic/Latino 4. What is your Race? (Check all that apply) Black/African American Asian American Indian Hawaiian Islander or Other Pacific Islander White Alaskan Native Other 5. What is your native or primary language? 6. If you are a male over 18 years old, have you registered for Selective Service? Yes SSR #: No N/A 7. Citizenship: US Citizen Documented Undocumented Refugee Other Legal Alien Other WIOA Eligibility Information 1. Have you been or are you a member of a family who received public cash assistance or SNAP in the last 6 months? Yes No 2. Do you have a disability? Yes No ADA Major Life Activity Impairment ADA and Employment Impairment 3. Are you pregnant? Yes No 4. Do you have any minor children? Yes No 5. If English is not your native or primary language, do you need help learning to speak/write/use English? Yes No 6. Are you homeless? Yes No 7. Are you a runaway? Yes No 8. Are you in foster care or were you previously in foster care? Yes No 9. Are you involved or were you involved in the juvenile court or adult justice system? Yes No 10. Do you receive or are you eligible to receive free or reduced price lunch? Yes No Educational Information 1. What is your education level? Withdrew from high school, no HS diploma Current high/junior high school student Completed 12th grade, but no HS diploma Obtained GED or equivalent High school graduate Some post high school education, no degree College Degree: Associate Bachelor Masters/Prof 2. What is your education status? I am not a student I am a student at a college or technical school I am student in a GED program I am a high school student, at grade level I am a high school student, behind grade level I am not attending high school Additional WIOA Intake Information 1. Do you need reliable child care? Yes No 2. Are you a single parent? Yes No 3. Do you have stable housing? Yes No 4. Do you use recreational drugs regularly? Yes No 5. Do you drink alcohol regularly? Yes No 6. Do you have reliable transportation? Yes No 7. Are you caring for an adult relative with a disability? Yes No 8. Do you need reliable dependent care? Yes No
