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Steps-to-Success
OMJCFC_ELIGDOCS V1.0 20181105
Welcome to the next steps to your new career. The OhioMeansJobs Columbus-Franklin
County Job Center offers a variety of services that will enhance your current skills and
abilities. We will provide resources and advisory sessions to prepare you to find the
career you desire.
As part of the enrollment process, we will need to verify information to determine your
eligibility in the programs that are offered. Should you have any questions about the list
below, please be sure to ask a Talent Development Specialist before your first
appointment.
Steps-to-Success Checklist
Please provide documents or verification of the following information for enrollment in
our Career Services programming:
Birth Date/Age
Authorization to Work
in the United States
Selective Service
Registration
(Males Only)
Verification of
Dislocation
(if applicable)
• Valid Driver’s
License
• Valid
State/Federal ID
• US Passport
• Passport Card
• Birth Certificate
• Social Security
Card
• Birth Certificate
• Citizenship/Alien
Status
• Right to Work
Form
• US Passport
• Passport Card
• Hospital Record
• Naturalization
Certification
• Selective
Service Card
• Internet
Verification
Note: Proof of Selective
Service is only required for
people who were born male
on or after January 1, 1960.
If you moved to the U.S.
from another country, ask us
about your requirements.
To check registration status,
please visit:
http://www.sss.gov
• Unemployment
Compensation
Award Letter
• Lay-off Letter
• Severance Letter
• RESEA letter
Please contact ________________________ at (_____) ____-_______ or
___________________________@___________._____ for additional
information about services, programs, or clarification of items needed for
enrollment in services at the OhioMeansJobs Columbus-Franklin County Job
Center.
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

20181010
WIOAAPP 2-0
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Date of Birth:
Age:
Social Security Number:
Educational Status:
Less than high school
Highest Grade Completed: _____
GED
High School Graduate
Some college (no degree)
Associate's degree
Bachelor's degree
Other diploma/degree
(please explain)
Other license/certification
(please explain)
Veteran Status:
No
Yes, and my dates of service
were:
to:
My discharge was within last
4 years
I receive VA benefits and/or
was discharged because of
service connected disability
I served during a war or
campaign/expedition
Yes, spouse of any person who
died in active duty or a service
connected disability
Yes, spouse of any member of
the Armed Forces serving on
active duty
Yes, less than 180 days.
Discharge or released under
conditions other than
dishonorable
Additional Information: Check all that apply
Single Parent
Substance Abuse Issues
Limited English Language (spoken)
Displaced Homemaker
Justice Involvement
Poor Work History
Basic Skills Deficiencies
School Dropout
Lacks Transportation
Incarceration
Runaway
Foster Child
Homelessness
Selective Service:
Registered
#
Not Registered
Not Applicable
Primary Language:
English
French
Spanish
Other:
Citizenship:
US Citizen
Non-Citizen, eligible
to work
Reg #:
Disability Status:
Yes - sometimes keeps
me from working
Yes - doesn't keep me
from working a job
None
Race / Ethnic Group:
White
Black / African American
Hispanic / Latino
Native American / Alaskan
Asian
Hawaiian / Pacific Islander
Other
Employment Status:
Employed
Not employed
Employed and
received notice of
termination
Gender:
Male
Female
Details:
20181010
WIOAAPP 2-0
Unemployment Information:
Claimant referred by RESEA
Claimant not referred by REA/WPRS
Exhaustee
Neither claimant nor exhaustee
Number of weeks
unemployed within
past 26 weeks:
Additional Family Information:
# of Dependents:
Total Family Size:
26 Week Includable
Income:
Ask an OMJCFC TDS for additional
clarification as needed.
Family Status:
Parent in one parent family
Parent in two parent family
Other family member
Single, no family members
in household
Public Assistance: Please check all that currently apply.
TANF
Food Stamps
SSI
Refugee Assistance
Trustee Assistance
General Assistance
Most Recent Work History:
Employer Name:
Job Title:
Address:
City: State:
Zip:
Phone:
Pay Rate:
Hrs/wk:
Start Date:
End Date:
Internship
OJT - Grant Based
OJT - Private
Apprenticeship
Position Type:
Unsubsidized Employment
Subsidized, Private
Subsidized, Public
Seasonal
Volunteer
Classification of Position:
Full Time
Part Time
Covered by Unemployment Ins:
Yes
No
Personal Benefits Available:
Yes
No
Reason For Leaving:
Terminated
Quit
Terminated but receiving
unemployment benefits
Laid Off
Still Employed
Additional Contact:
Name:
Relationship:
Address:
City:
State:
Zip:
Phone:
Email Address:
20181010
WIOAAPP 2-0
CONFLICT OF INTEREST ACKNOWLEDGEMENT: Do you have a business or personal relationship with any
OMJCFC staff, elected official(s), or any other individual(s) or organization(s) that directly or indirectly
manage the Workforce Innovation and Opportunity Act Program?
NO YES Name(s): __________________________________________
Job Seeker Signature: ______________________________________________ Date: _______________
Acknowledgement: By signing, I certify that the information I have provided is accurate to the best of my
knowledge.
Applicant Signature: ________________________________________________ Date: ________________
OMJCFC Representative Signature: ____________________________________ Date:________________
Release of Information Authorization and Consent for Release of Information:
I, the undersigned, do hereby authorize any and all persons, firms, and entities of any kind or character to release to the OhioMeansJobs Columbus-
Franklin County Job Center upon presentation of this authorization, any and all information that such persons, firm or entity may have with regards to
me, including, but not limited to, copies of personal files, past history, or present status. This information may be divulged to the OMJCFC Job Center
upon written request that accompanies a signed copy of this authorization. Any person, firm, or entity, governmental or otherwise, releasing information
hereunder is hereby released from any and all liability of any kind or character because of such release to the OMJCFC. The OMJCFC Job Center will
keep any such record in the strictest of confidence and only for purposes for which OMJCFC has been formed.
Consent for Release of Information:
I, the undersigned, do hereby authorize OMJCFC to release any information from my personal files to any agency or individual for the purpose of
expediting the service that OMJCFC will procure for me. I understand that I have the right to review any and all such personal information or other
information pertaining to me upon written request. I further understand that this information is to be used to determine eligibility verification,
statistical analysis, reporting data as required by federal law, and to aid in procurement of services for me. I hereby release and discharge OMJCFC
of any liability of any kind or character with respect to the release of information herein authorized. The records so released will be in the strictest
confidence and be used only for those purposes for which OMJCFC was formed.
Participant: OMJCFC Staff:
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Revised: KAC 09082017
Ohio Means Jobs | Columbus-Franklin County
Statement of Customer Understanding
Please read each statement below completely. After reading, initial each statement certifying that you have read and
understand your responsibilities as a Workforce Innovation and Opportunity Act (WIOA) participant.
I have read and understand the above statements and understand that any failure to adhere to them may result in termination of
participation in the WIOA Program.
_____________________________________________________ ________________________________________
Customer Signature Date
_______________________________________________________ ________________________________________
Staff Signature Date
I understand that the WIOA Program is a federally funded employment program and that the main focus of this
program is to assist me with becoming job ready and obtaining employment that will lead to self-sufficiency.
I understand that the WIOA Programs offers services designed to assist me in identifying a career goal, becoming
job ready, and finding employment opportunities.
I understand that in order to move forward, I am responsible to complete certain activities as identified in
collaboration with my assigned Talent Development Specialist and myself that will assist me in becoming job
ready and identifying employment opportunities that match my qualifications.
I understand that not every customer will need services at every level in order to find employment leading to self-
sufficiency and that I will work with my Career Planner to identify the WIOA path appropriate for me.
I understand that I am required to actively seek employment and document my job search while participating in the
WIOA Program and that the job search process is ongoing until I have found employment and/or it has been
determined that I am unable to find employment leading to a self-sufficient wage with the skills and qualifications I
currently possess. This statement may not be applicable in all cases – initial to indicate you have read and/or
agree.
I understand that it is my responsibility to submit updated job search logs at each appointment (if applicable).
I understand that I am required, as a WIOA Participant, to provide documentation of employment obtained at any
time after beginning the WIOA process. I will submit an employment verification or paystub as soon as one is
available.
I understand that I am responsible for attending each scheduled appointment or contacting my Talent
Development Specialist in a timely manner to reschedule if I am unable to attend a scheduled appointment.
I understand that my active participation in the WIOA Program does affect my appropriateness for certain services.
I understand that training services and work based training is possible under WIOA services. I
further understand that WIOA training services are not an entitlement and that it is, under no
circumstances, a guarantee that I will be approved for WIOA Scholarship funds.
I understand that it is my responsibility, in order to be considered for WIOA training services, to complete all
required steps in the WIOA process.
I understand that I am not, under any circumstances, to start a training program under the assumption that I will
receive WIOA funding until I have received notification of approval and that if I begin a training program prior to
receiving notification of approval, I assume all financial responsibility.
I understand that WIOA Scholarship funds cannot be applied retroactively or as reimbursement for any reason.
I understand that if I intend to apply for WIOA scholarship funds, it is my responsibility to check on the status of
any existing student loans and that if I have a loan in default, I am responsible for contacting my loan holder and
applying for deferment or scheduling an acceptable payment arrangement and providing documentation of my
loan status.
I understand that if I intend to apply for WIOA Scholarship funds, it is my responsibility to complete the Free
Application for Federal Student Aid (FAFSA) and document the status of my financial aid eligibility.
I understand that I may only apply for WIOA Scholarship funding in approved occupations identified as high-
growth industries and at WIOA approved training providers.
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20181009 BIQ V1-0
Career Services:
Background Information
Participant's Name:
Participant's DOB:
Participant's Email Address:
Date:
OhioMeansJobs Columbus-Franklin County is your employment resource. We understand that looking for a job can be
stressful. You might be unsure of where to turn or what to do next. You might just want a refresher on searching for a job,
interviewing and standing out as a candidate. Whatever the situation, OhioMeansJobs Columbus-Franklin County can
help. Please complete this questionnaire to provide additional information that will be valuable in developing your
individualized employment plan. Should you have questions or need clarification, please ask a staff member.
What would you like to accomplish
with the assistance of services
provided at OhioMeansJobs
Columbus-Franklin County?
What are your short and long-term
career goals? (Please include hours
and wage rate)
What job and employability skills do
you have?
What job and employability skills
would you like to improve?
What job search methods have you
been using? Have you had any
interviews recently?
Do you believe you have any
challenges that are preventing you
from finding employment? If so,
please explain. (Transportation,
child care, education, other
background issues, computer skills,
etc.)
Do you have a disability or special
accommodation need for
employment?
Rat
e the following:
Computer Skills
Current Resume
Interview Skills
Work History
Good
Good
Good
Good
Fair
Fair
Fair
Fair
Needs Improvement
Needs Improvement
Needs Improvement
Gaps in Employment
OMJCFC_INTK_Wrk Hstry 2018_NOV2
Ohio Means Jobs | Columbus-Franklin County
Employment History
Name: _______________________________________________________ Date: _______________________
Company Name:
Job Title:
Start Date:
End Date:
Hourly Rate:
□ Full Time □ Part-Time
Reason for Leaving:
Duties:
Company Name:
Job Title:
Start Date:
End Date:
Hourly Rate:
□ Full Time □ Part-Time
Reason for Leaving:
Duties:
Company Name:
Job Title:
Start Date:
End Date:
Hourly Rate:
□ Full Time □ Part-Time
Reason for Leaving:
Duties:
Company Name:
Job Title:
Start Date:
End Date:
Hourly Rate:
□ Full Time □ Part-Time
Reason for Leaving:
Duties:
Company Name:
Job Title:
Start Date:
End Date:
Hourly Rate:
□ Full Time □ Part-Time
Reason for Leaving:
Duties:
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Completed 3 July 2021

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