WIOA Application
Entered on 09/24/2023
Last Name
First Name
Middle Initial
Social Security # (optional)
Street Address
Mailing Address
City
Zip Code
County
E-mail Address
Phone #
Cell #
Alternate Contact Name
Alternate Contact Phone #
U.S. Citizen
Gender
Date of Birth
If you were born a male on or after 1/1/1960, are you registered with Selective Service? No Yes Not Required Less Than 18 Years Old Waived
Eligible Migrant & Seasonal Farmworker Status
Hispanic or Latino
Education Status
Highest Grade Completed
Employment Status
High School
Ltd Level of Literacy / Basic Skills Deficient
Preferred Language
Office you would like your application sent to: Ashland Barron Chippewa Clark Douglas Dunn Eau Claire Iron Marathon MN Resident Pepin Pierce Polk Price Rusk Sawyer St. Croix Taylor Washburn
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.
Eligibility Characteristics
Race
Military
Public Assistance
Fuel Assistance
W2/TANF
Kinship Care/TANF
Exhausting TANF (Within 2 years)
SSI
Refugee
Refugee Cash Assistance
Homeless
FoodShare
Childcare/Badger Care
WIC
Free and Reduced Lunch
General Assistance
Needs Additional Assistance
Faces Serious Barriers
Other Income-based Public Assistance
List all household members (including yourself) and their approximate gross income for the LAST SIX MONTHS.
Household Member
Relationship
Age
6 Month Income
6 Mos. Start Date
6 Mos. End Date
12 Month Income
List all past employers over the last 10 years - begin with the most recent.
Employer
Position
Hrs/Week
Start Datemm/dd/yyyy
End Datemm/dd/yyyy
Ending Wage
WagePeriod
Reason For Leaving
Laid-off Workers, Farmers, and Displaced Homemakers
Lay-off Date (planned or actual)
Lay-off Employer
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
Displaced Homemakers:
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.