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

Hispanic or Latino

Education Status

Highest Grade Completed

Ltd Level of Literacy / Basic Skills Deficient

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.

List  all household  members (including yourself) and their approximate gross income for the LAST SIX MONTHS. 

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

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.