Entered on 01/25/2021
Social Security # (optional)
Alternate Contact Name
Alternate Contact Phone #
Date of Birth
If you were born a male on or after 1/1/1960, are you registered with Selective Service?
Hispanic or Latino
Highest Grade Completed
Ltd Level of Literacy / Basic Skills Deficient
Office you would like your application sent to:
Registered with Job Center of Wisconsin
The information below is necessary to determine if you are eligible for specific programs. Indicate "Yes" to all that apply
Indicate "Yes" if you are CURRENTLY receiving, or received in the last 6 months.
Exhausting TANF (Within 2 years)
Refugee Cash Assistance
Free and Reduced Lunch
all household members (including yourself) and
their approximate gross income for the LAST SIX MONTHS.
Annual Gross Income
List all past employers over the last 10 years - begin with
the most recent.
Reason For Leaving
Laid-off Workers, Farmers, and
Lay-off Date (planned or actual)
Dislocated (laid-off) in the last 5 years
Reason Self-Employment ended
Received a verbal or written termination notice
Unlikely to return to previous occupation
No Recall Date
Type of Dislocation (Lay-off)
Attended Rapid Response Session
Rapid Response Session Date
Dependent on Family Member
No Longer Supported
Dependent on Spouse who is a member of the Armed Services
Family Income is Significantly Reduced
Computer Skills Survey
Workforce Resource Inc. is an equal opportunity employer and service provider. If you need assistance to access services or materials in an alternate format, call 1-800-472-5522.