Yes No: Legal. Do you have ANY prior felonies, misdemeanors or family court issues now or in your past?
(Please note that we reserve the right to run background checks on applicants and ask for more information.)
If Yes, list court issue: ______________________________________________________________________________
Yes No: Are there any health issues now or in your past that would affect you getting employment in your chosen
field? (Example: weight restrictions, stand/sitting restrictions, limited mobility issues, vision/hearing difficulties). If so, please
provide a doctor’s note that these restrictions will not prevent you from performing the duties of your job with reasonable
accommodations.____________________________________________________________________________________
Yes No: Are there any DMV issues now or in your past that would affect you getting employment in your chosen
field? If you are applying for CDL truck driver training, attach a background check from the DMV._________________
Additional Eligibility Questions
To comply with Federal reporting requirements for Workforce Investment Act funded programs, we are required to collect
additional personal information from customers when they begin receiving a more intense level of service. In addition, under the
American Recovery and Reinvestment Act of 2009, individuals who are low income or public assistance recipients must receive
priority for service under certain aspects of our programs. The provision of this additional information is VOLUNTARY. Staff will be
happy to assist you to complete this questionnaire.
Number of people (including self) in the household related by blood or marriage: ______
Total yearly household income for above counted individuals: $_________________
Yes No Are you a Veteran or a Spouse of a Veteran?
Yes No Do you or are you a member of a family that receives public assistance? If so check all that apply
TANF Food Stamps
General Assistance Medicaid
Section 8 Housing Supplemental Security Income (SSI-SSA)
Refugee Cash Assistance
Yes No If you or your family are not receiving public assistance, do you believe you or your family might
meet low-income criteria? If yes, what is your total family income $ __________ per _______
Yes No Are you a person with a disability whose own income might meet low-income criteria?
If yes, what is your income? $________ per __________
Yes No Were you involved in a large layoff of either: 25% of employee at company or 50 or more workers
were laid off?
Yes No Did the company you work for close?
Yes No Are you on unemployment? If yes, what is your weekly UI benefit?_____________________
Yes No Were you a stay at home parent (or employed part time), supported by the income of another
family member, but are no longer supported by that income and find that you must now return
to work full-time to help support the household? (This could include a family member losing a job,
divorce, separation, and death in the family)
Yes No Is your native language a language other than English?
If so, please indicate your native language: ______________________
Yes No Do you have difficulty speaking, reading, writing or understanding English?
Yes No Are you a single parent?
(Single, separated, divorced or widowed with primary responsibility for one or more dependent children under age 18)
Yes No Are you homeless? (Lack a fixed, regular, adequate nighttime residence, or is your primary nighttime residence a
publicly or privately operated shelter)
Yes No Are you currently a foster child?
Yes No Are you an offender? Definition: Have you been subject to any stage of the criminal justice process for committing
a status offense, or have a record of arrest or conviction [ANY Felonies or misdemeanors EVER]
