Chippewa Fresh Start YouthBuild Application
Entered on 03/06/2021
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
Employment Status
Hispanic or Latino
Education Status
Highest Grade Completed
High School
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.
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
List all household members (including yourself) and their approximate gross income for the LAST SIX MONTHS.
Household Member
Relationship
Age
Gross Income
Annual Gross 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
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.