Equal Opportunity Employer/Program
Auxiliary Aids & Services Available to Individuals with Disabilities
Please complete the following form to the best of your abilities.
PART I: APPLICANT INFORMATION
First MI Last
Social Security Number
Male Female Do Not Wish to Answer
African American American Indian/Alaskan Native Asian White
Hawaiian/Pacific Islander I do not wish to answer
Are you of Hispanic or Latino Origin?
Yes No I do not wish to answer
What is your primary
language if NOT English:
Mobile Work Home Other
Email: Contact Preference:
Residential Address: City:
Zip Code: County of Residence:
Mailing Address Check here to use residential address City State: Zip Code: County
Alternate Contact: Relationship Phone Number
Are you legally authorized to work in the United States?
Are you a United States Citizen?
Citizen of US or US Territory U.S Permanent Resident
Alien/Refugee Lawfully Admitted to the US None of the Above
If Alien/Refugee Alien Card #: Exp. Date:
What is your current employment status?
Working Fulltime Working Part-time Not Working Never Worked
Have you registered for the Selective Service (www.sss.gov)?
(Males born on or after 1/1/1960, ONLY)
Yes No NA Documented Exemption
Do you have a disability?
Are you currently in the military, a veteran or a spouse of a member of the armed forces who is on
active duty or a veteran?
Have you previously enrolled in WIOA funded training?
If YES, please complete the following:
Name of School attended: Name of Training Program: Completion Date:
Did you complete the training? If no, why not:
Did you find a job after you completed the training?
If YES, was the job related to the training you received?
Dates of Employment: (mm/dd/yy)
What are your future training goals?
WorkSource Metro Atlanta
WIOA Eligibility Application
If Yes, do you need additional support?