WIOA Application

Entered on 09/24/2023

Last Name	First Name		Middle Initial		Social Security # (optional)	(example: 555-55-5555)
Street Address	Mailing Address		City	State	Zip Code
County	E-mail Address		Phone #	(example: 715-222-5555)	Cell #
Alternate Contact Name	Alternate Contact Phone #	(example: 715-222-5555)			U.S. Citizen
Gender	Date of Birth	(example: 12/01/1962)	If you were born a male on or after 1/1/1960, are you registered with Selective Service?		Eligible Migrant & Seasonal Farmworker Status
Hispanic or Latino	Education Status		Highest Grade Completed		Employment Status
	High School		Ltd Level of Literacy / Basic Skills Deficient		Unemployed for 27 or more consecutive weeks
			Preferred Language		Do you require an Interpreter?

Office you would like your application sent to:

Registered with Job Center of Wisconsin

Assistance Desired

Specify Assistance

Immediate Employment

Education

I would like assistance with:

Foundational Needs

Learning about resource's for low income individuals and families

Budgeting and paying my bills

Career Planning

Understanding how my skills and experience relate to new jobs

Deciding what jobs are a good fit for me

Job Seeking

Filling out applications

Developing a resume

Improving my interviewing skills

Learning how to find a job

Getting Job Leads

Assistance will depend on eligibility & available funding at the time of request.

Job Keeping

Improving attendance and punctuality at work

Improving quality and productivity at work

Improving supervisor and co-worker relations at work

Basic Skills

Improving my reading skills

Improving my math skills

Improving my computer skills

Training

Deciding which training program would be best for me

Deciding which school would be best suited for me

Paying for tuition and books

Help with transportation costs for training

Childcare costs while I go to school

Needs not covered above

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
Limited English	American Indian or Alaskan Native	Military Service
Homeless/Runaway	Asian	Transitional Service Member
Offender/Ex-Offender	Black or African American	Veteran Status
	Hawaiian or Pacific Islander	Active Military Spouse
Foster Child	White	Active Duty Begin Date
Aged Out Of Foster Care	Other	Active Duty End Date
Disability	Unknown	Campaign Veteran
SSDI (in last 6 mos.)		Disabled Veteran
Social Security Ticket Holder (within last 6 mos.)	Cultural Barriers	Spouse of Veteran
Alcohol or Drug Abuse issues
Pregnant/Parenting and less than 25 years old
Parent of Child Under 18
Parent of Child Under 18 Who Does Not Live With You

Single Parent
Current Pell Grant Recipient
Unemployment Insurance Status

	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

		TOTAL	0			0

List all past employers over the last 10 years - begin with the most recent.

Employer	Position	Hrs/Week	Start Date mm/dd/yyyy	End Date mm/dd/yyyy	Ending Wage	Wage Period	Reason For Leaving

Laid-off Workers, Farmers, and Displaced Homemakers
Lay-off Date (planned or actual)	Lay-off Employer
Reason Self-Employment ended	Plan To Retire (or otherwise leave the workforce)	Received a verbal or written termination notice
Unlikely to return to previous occupation	Plan To Transfer to another position or location with my current employer outside of commuting distance	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
On a scale of 1 - 5, please indicate the best choice for each of the following:
	Very Skilled	Skilled	Somewhat Skilled	Not Very Skilled	Not Skilled
Using email	1	2	3	4	5
Using word processing software (for example, Microsoft Word)	1	2	3	4	5
Creating and using electronic spreadsheets (for example, Microsoft Excel)	1	2	3	4	5
Using databases (for example, Microsoft Access)	1	2	3	4	5
Creating or Modifying databases	1	2	3	4	5
Programming using computer languages	1	2	3	4	5

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.

A Proud Partner of the AmericanJobCenter Network