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
Applicant Name:
First MI Last
Application Date:
Birth Date:
Social Security Number
- -
Gender:
Male Female Do Not Wish to Answer
Race:
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:
Primary Phone
Phone Type:
Mobile Work Home Other
Email: Contact Preference:
Phone Email
Residential Address: City:
State:
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?
Yes No
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?
Yes
No
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?
Yes
No
Have you previously enrolled in WIOA funded training?
Yes
No
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:
Yes No
Did you find a job after you completed the training?
Yes
No
If YES, was the job related to the training you received?
Name of Employer:
Dates of Employment: (mm/dd/yy)
From
To
What are your future training goals?
WorkSource Metro Atlanta
WIOA Eligibility Application
If Yes, do you need additional support?
Yes
No
Equal Opportunity Employer/Program
Auxiliary Aids & Services Available to Individuals with Disabilities
PART II: ELIGIBLITY
DISLOCATED WORKER Category
Within the last 12 months, have you received notice of termination or layoff from your job or
received documentation that you are separating from the military?
Yes No
If YES, please provide the date of termination or separation
(mm/dd/yy)
If YES, please provide the information of your previous employer
Employer Name
Employer County
Address
City
State
Zip Code
ADULT Category
In the past six months, have you or anyone in your family received the following public assistance:
Temporary Assistance for Needy Families (TANF)
Yes No
Supplemental Nutrition Assistance Program (SNAP)
Yes No
Supplemental Security Disability Income (SSDI)
Yes No
Supplemental Security Income (SSI)
Yes No
Any other forms of public support?
Yes No
Explain:
PART III: FAMILY COMPOSITION OF INCOME
Family Composition: List each family member currently living in the home.
Names of Family Members
Including Applicant
Relationship
Age
Social Security #
(over 14 years of age)
Total Gross Income
(Six Months Prior to Application)
APPLICANT/SELF
List other sources of financial support and
amounts received:
EXAMPLES: child support, unemployment, Social Security
1
2
3
Total # in
Household:
Total Household
Income
NOTE: Falsification of data on this form is a crime against Federal and State laws and is punishable by a fine or
imprisonment or both and will require repayment of any monies paid to or on behalf of the applicant while in training.
Equal Opportunity Employer/Program
Auxiliary Aids & Services Available to Individuals with Disabilities
Please complete the following form to the best of your abilities
Are you currently in school? YES NO
If YES, Name of School: Program:
Highest School Grade Completed: None Grade School Middle School 10
th
11
th
12
th
High school diploma or equivalent received (GED) YES NO
Highest Qualification Level Completed:
Do NOT complete for education levels
of less than high school or high school
equivalency diploma
Certificate of Attendance/Completion (Disabled Individuals)
High School Equivalency Diploma
High School Diploma
1 Year at College or a Technical or Vocational School
2 Years at College or Technical or Vocational School
3 Years at a College or Technical or Vocational School
Vocational School Certificate
Associates Degree
Bachelor’s Degree
Master’s Degree
Doctorate Degree
Specialized Degree
Course of Study
Issuing Institution
Do you possesses any certifications or licenses? YES NO
If YES, list below:
1
Certificate/License Issuing Organization
Completion Date: State Country:
2
Certificate/License
Completion Date: State Country:
3
Certificate/License
Completion Date: State Country:
Issuing Organization
Issuing Organization
PART IV: EDUCATION HISTORY
Equal Opportunity Employer/Program
Auxiliary Aids & Services Available to Individuals with Disabilities
APPLICANT ATTESTATION:
The information I have provided in this application is true and accurate. I understand that any false or
misrepresented information may adversely affect my eligibility for services or disqualify me from receiving assistance.
Applicant Signature Date
____________________________________
Applicant Printed Name
PART V: WORK EXPERIENCE
Please list your work experience for the past 3 jobs your most recent job held.
Name of Employer:
Occupation Title:
Type:
Full Time Part-Time
Employment Dates: (mm/dd/yy)
From To
Wage/Salary
$
City
County
State
Reason for leaving job (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:
Name of Employer:
Occupation Title:
Type:
Full Time Part-Time
Employment Dates: (mm/dd/yy)
From To
Wage/Salary
$
City
County
State
Reason for leaving job (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:
Name of Employer:
Occupation Title:
Type:
Full Time Part-Time
Employment Dates: (mm/dd/yy)
From To
Wage/Salary
$
City
County
State
Reason for leaving job (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:
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