Job Seeker Services

MONTEREY COUNTY WORKFORCE DEVELOPMENT BOARD
WORKFORCE INNOVATION & OPPORTUNITY ACT (WIOA) APPLICATION

Application Eligibility Date
MM slash DD slash YYYY
Last 4 Digits of Your Social Security #*
CONTACT INFORMATION
Name*
First Middle Initial Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Phone Type
May we send you text messages?
- Yes
- No
Email*
DEMOGRAPHIC INFORMATION
Date of Birth*
MM slash DD slash YYYY
Gender*
Selective Service (MALES ONLY)
Military Status*
If you are a Veteran you will be required to complete a WIOA Veteran Form at enrollment
Disability*
If “Yes”, you will be required to complete a WIOA Disability Form at enrollment
Authorized to Work in U.S.*
If U.S. Permanent Resident or Alien/Refugee:
Alien/Visa Registration #
Expiration Date
MM slash DD slash YYYY
Hispanic Heritage*
Race*
EMPLOYMENT INFORMATION
Employment Status*
If Employed, are you underemployed?
Registered Apprenticeship Program
Unemployment Insurance Eligibility
Number of Weeks Unemployed
Current/Previous Hourly Rate
Occupation
DISLOCATED WORKER ELIGIBILITY
Layoff Date
MM slash DD slash YYYY
Employer Name
Employer Address
Street Address Address Line 2 City State ZIP Code
Dislocation Hourly Rate
EDUCATION INFORMATION
Currently enrolled in school*
Highest Education Level*
High School Diploma or Equivalent Received*
PUBLIC ASSISTANCE
Temporary Assistance for Needy Families (TANF) – Recipient*
Supplemental Security Income (SSI) - Recipient*
General Assistance (GA)*
Supplemental Nutrition Assistance Program (SNAP)*
Refugee Case Assistance (RCA)*
Social Security Disability Insurance Income (SSDI)*
Receiving services under SNAP Employment & Training Program*
Receiving, or has been notified will receive, Pell Grant*
Ticket to Work Holder Issued by the Social Security Administration*
Foster Child (state or local payments are made for applicant)*
Youth currently living in high-poverty area*
Youth currently receives, or is eligible to receive free or reduced lunch under the Richard B. Russell National School Lunch Act*
BARRIERS
English Language Learner*
Basic Skills Deficient/Low Levels of Literacy*
Homeless*
Ex-Offender – individual has been arrested/convicted of a crime*
Displaced Homemaker*
Within 2 years of exhausting TANF lifetime eligibility*
Hawaiian Native*
American Indian/Alaskan Native*
Single Parent (including single pregnant women)*
Cultural Barriers*
FAMILY INCOME
Family Size*
Past 6 months Family Income*
APPLICANT CERTIFICATION STATEMENT
I certify that the information on this application is accurate to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of rights in the WIOA Program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for WIOA. I further understand and agree that my social security number and other information on this application will be provided to other government agencies as required by law.
Signature*
Date*
MM slash DD slash YYYY
Parent/Guardian Signature (if applicable)
Date
MM slash DD slash YYYY