Training and Education - WIOA Adult/Dislocated Worker Program Pre-Application

First Name *

Last Name *

Middle Initial

Last 4 Social Security #

Please use numbers only

Disclosure of the last four digits of your social security number is voluntary. It is requested however, pursuant to Privacy Act of 1974. Social security numbers will be used by CareerSource Capital Region for the sole purpose of system review to determine our overall level of efficiency.

Address

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

County (Must live in Gadsden, Jefferson, Leon or Wakulla to qualify) *

Gadsden
Jefferson
Leon
Wakulla

Email *

Cell Phone or Home Phone *

Area Code

Phone Number

Alternate Contact Number

Area Code

Phone Number

What type of career are you most interested in?

If applicable, which organization referred you to this Pre-Application or the WIOA program?

Please complete the following questions to help us determine your potential eligibility for the WIOA program. The more accurate the information you provide, the easier it will be for us to enroll you in our program. All of the information collected is confidential.

Are you a US Citizen, Naturalized Citizen, or are you a legally admitted alien or refugee? *

Yes
No
N/A

Are you a veteran who has served at least 180 days on active duty or a spouse of a veteran? *

Yes
No
N/A

Males 18 yrs. old or older only: Are you registered with Selective Service? *

Yes
No
N/A

What is the highest level of education that you have achieved? *

Do you receive Re-employment assistance? *

Yes
No
N/A

Have you exhausted your Re-employment assistance? *

Yes
No
N/A

Are you currently receiving a TANF grant? *

Yes
No
N/A

Are you currently receiving food stamps or have you received food stamps in the last 6 months? *

Yes
No
N/A

How Did You Hear About This Program?

Staff Person
CareerSource Capital Region Website
Referral from Another Agency / Organization
Advertisement/Public Notices (Radio, Local News, SmartTV/Connected TV, etc.)
Social Media (Meta - Facebook/Instagram, TikTok, or Linkedin)

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Training and Education - WIOA Adult/Dislocated Worker Program Pre-Application

* Required field

Please complete the following questions to help us determine your potential eligibility for the WIOA program. The more accurate the information you provide, the easier it will be for us to enroll you in our program. All of the information collected is confidential.