Updated October 2019
YES Duluth Application
Duluth Workforce Development
402 W 1
St, Duluth, MN 55802
Fax: 218-730-5952 | Phone: 218-302-8400
n Date:_________________________ Referred By: _________________________________________
Personal Information
Middle Name: ____________________
Apt # City:_________________ ZIP:
Alternate Phone:____________________________________
Birth Date:
Age Today:
First Name:
Last Name:
Street Address:
Email Address:
Gender: Male Female
Prefer not to self-identify
If yes, Active Duty Start:_______________ End Date:_________________
Veteran status: I am a veteran Yes No
I am currently attending High School or Junior High Yes No
If yes, I am attending (circle one): ALC Denfeld East HS Harbor City Int’l Other_________________
If yes, are any of your classes online? Yes
If no, what is the highest grade completed?________________
I have completed ABE/GED Orienta�on Yes No
I am working on my GED Yes No I am working on my GED online Yes No
I have a goal of getting my GED Yes No
I am attending post-secondary school (college or technical) Yes No
If yes, I am attending: LSC WITC Fond-du-Lac UMD CSS Other___________________
My educa�on goal________________________________________________________________________________
Employment status:
I am currently employed Yes No
If no, my last day of work was__________________
If yes, my job is: Part-Time Full-Time Temporary
My employment goal______________________________________________________________________________
School Status:
Return Completed
Application to:
Updated October 2019
Eligibility Information
Are you or have you been in foster care?
Are you recovering from chemical
Are you homeless, a runaway or in
temporary housing?
Do you have a parent who is recovering from
chemical dependency?
Are you an English language learner or
limited in the use of the English language?
Have you been convicted of a misdemeanor,
gross misdemeanor or felony?
Are you pregnant or parenting?
Have you currently dropped out of school?
Have you been diagnosed with a
Does a disability limit your abilities in
Did you or do you have an IEP in school?
Did you or do you have a 504 plan in school?
o you or family members in your home receive any of the following assistance?
ANF/MFIP (MN Family Investment Program)
efugee Assistance
ood Support (known as SNAP)
SI (Supplemental Security Income)
neral Assistance
(Social Security Disability Insurance)
Free/Reduced School Lunches (applicant only)
Household Income
Please list all family members living in your household and their income for the last six (6) months. List all sources of
income including wages, retirement, child support, spousal support, financial benefits, unemployment insurance, and
school aid (excluding Pell grants).
Family Member Name
Relationship to
Source of Income
Total Income in
Past 6 Months
Actual Family Size
Eligible Family Size
Total Past Six Months
Total Annualized
Certification Statement
I certify the information provided is true to the best of my knowledge. I understand the information I have provided is subject to
review and verification and I may be required to provide documents to support the information on this application. I understand I
am subject to immediate termination if I am found ineligible after enrollment and may be prosecuted for perjury.
Applicant Signature Date
_________________________________________________________________ ___________________
If under 18 or under legal guardianship, Parent/Guardian Signature Date