Adult and Dislocated Worker Programs Application

Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone *

(###)

###

####

Cell Phone *

(###)

###

####

Checkbox *

Do you accept text messages?

Yes

No

Message Phone *

(###)

###

####

Relative's Name *

First Name

Last Name

Relative's Phone *

(###)

###

####

Birthdate *

MM

DD

YYYY

Sex (at birth) *

Male

Female

Are you Hispanic or Latino? *

Yes

No

Prefer not to answer

What is your Race? *

Select one or more:

White or Caucasian

Asian or Asian American

Black or African American

Hawaiian or Other Pacific Islander

American Indian or Alaska Native

More than one race

Prefer not to answer

Do you acknowledge a disability that substantially limits one or more major life activity? *

Yes

No

If yes, do you need special accommodations for the disability?

Yes

No

Do you receive Social Security Disability Insurance? *

Yes

No

Do you have trouble solving problems OR reading, writing, and speaking English at a level necessary to function on the job? *

Yes

No

Is English your primary language? *

Yes

No

Do you live in a family or community where English is not the primary language spoken? *

Yes

No

Are you registered with Selective Service? *

Yes

No

Are you a U.S. Citizen? *

Yes

No

If no, are you a permanent resident alien?

Yes

No

If no for both above, are you a lawfully admitted refugee, asylees, parolee, or other immigrant authorized to work in the United States?

Yes

No

N/A

Are you a veteran? *

Yes

No

Have you registered with Arkansas Job Link? *

Yes

No

Are you an Arkansas Works referral from the state Medicaid expansion program? *

(Arkansas Works is a Governor's initiative DHS program that refers DHS clients to DWS job service staff for employment assistance)

Yes

No

Have you been subject to any stage of the criminal justice process for committing an offense or delinquent act, OR do you have trouble obtaining or keeping a job because of an arrest or conviction? *

Yes

No

Are you a single parent (custodial or non-custodial), or a pregnant woman? *

Yes

No

Do your customs, beliefs, or practices serve as a hindrance to employment (cultural barrier)? *

Yes

No

Do you or a family member currently receive (or received in the last 6 months) any of the following?

Check all that apply:

SNAP

TEA

Work Pays

Supplemental Security Income (SSI)

Are you within 2 years of exhausting your lifetime TANF eligibility? *

Yes

No

Are you homeless (lack a fixed, regular, and adequate nighttime residence)? *

Yes

No

Do you certify that all the income sources above are all the sources of income for your family? *

Yes

No

Which best describes your current employment status? *

Check all that apply:

Employed working for wages, self-employed, or working 15+ hours per week unpaid in family business. ("Employed" includes if you are away from job because of vacation, leave, etc.)

Part-time (PT is less than 30 hrs/wk or considered PT by your employer)

Full-time

Self-Employed

Employed, but received termination notice from employer/military

Not employed (not working, but available for work and looking for work)

Exhausted Unemployment Benefits, and don't have an appropriate job

Have been unemployed for 27 or more consecutive weeks, but have been looking for work and was available for work during the entire time

Not in labor force (not employed and have not actively been looking for work)

Are you a migrant or seasonal farm worker? *

Yes

No

Do you currently receive Unemployment Benefits? *

Yes

No

Have you received Unemployment Benefits in the past? *

Yes

No

Have you recently been laid off or given notice that you will be laid off? *

Yes

No

Layoff date

MM

DD

YYYY

Did you own a business that recently closed because of a disaster or local economic reasons?

Yes

No

Closure date

MM

DD

YYYY

Are you a displaced homemaker (a person who has been providing unpaid services to family members in the home and has been dependent on the income of a family member, but is no longer supported by that income and is unemployed or underemployed and is experiencing difficulty obtaining or upgrading employment)?

Yes

No

Are you (or were you) the dependent spouse of a member of armed forces on active duty, and the family income is significantly changed because of a deployment, a call or order to active duty, a permanent change of state, or the service-connected death or disability of the member?

Yes

No

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Do you have a high school diploma or GED? *

Yes

No

Do you have a college degree or certificate? *

Yes

No

Do you have college work toward an unfinished certificate? *

Yes

No

Are you currently enrolled in postsecondary education (college, technical school, etc.)? *

Yes

No

I authorize the local provider of WIOA Title 1-B Adult and Dislocated Worker Programs (hereafter called WIOA) to use the information in this application to help me reach my goals. I also authorize them to exchange pertinent personal information with other service providers as appropriate to help meet my needs and reach my goals. I understand that all exchanged information shall remain private and confidential in accordance with the confidentiality policies of each agency receiving and sharing information.(required) *

Yes

I authorize the Social Security Administration, the Arkansas Department of Workforce Services, the Arkansas Department of Human Services, the Arkansas Department Career Services, the Arkansas Department of Higher Education, the Arkansas Department of Corrections, the local and state police and sheriff departments, appropriate WIOA One-Stop partners, employers (past and present), educational entities, and other appropriate WIOA entities to share with WIOA information that can help me establish eligibility for services, reach my goals, and document my successes. Information shared may include, but is not limited to, information that could help me become eligible for appropriate programs; assessments; benefits received from SNAP, TANF, Social Security, SSI, and/or Unemployment Insurance; grants, scholarships, and loans received for training; grades, attendance records, and credentials for training or work experiences provided by (or for which supportive services are provided by) WIOA, and other information that could help me meet my goals and document my outcomes.(required) *

Yes

I agree to hold harmless the Arkansas Workforce Center, the Local Workforce Development Board, WIOA, or entities releasing information to WIOA, for information released according to the confidentiality guidelines of such agencies.(required) *

Yes

I agree that a copy of this authorization may be used as an original.(required) *

Yes

This authorization shall continue for one (1) year from the date of exit from the WIOA program or until such time that WIOA is notified in writing by the applicant that the authorization is canceled.(required) *

Yes

I understand that submission of this application and/or eligibility determination does not guarantee enrollment.(required) *

Yes

I certify that I have read and fully understand all questions asked on this application, and that I should ask for clarifications if needed before I sign this application.(required) *

Yes

I certify this information to be true to the best of my knowledge, and there is no intent to commit fraud. I am aware that if I am found ineligible after starting the program, I will not be allowed to continue in the program. I am also aware that legal action may be taken against me if it is found that I knowingly provided false or fraudulent documentation during the eligibility process.(required) *

Yes

It is against the law for recipient of Federal financial assistance to discriminate on the following basis:

Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and

Against any beneficiary of programs financially assisted under Title I of the Workforce Innovation and Opportunity Act (WIOA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his/her participation in any WIOA Title I-financially assisted program or activity.

The recipient must not discriminate in any of the following areas:

Deciding who will be admitted, or have access, to any WIOA Title I-financially assisted program or activity:

Providing opportunities in, or treating any person with regard to, such a program or activity; or

Making employment decisions in the administration of, or in connection with, such a program or activity.

What To Do If You Believe You Have Experienced Discrimination

If you think you have been subjected to discrimination under a WIOA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either:

• the recipient’s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or

• the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC 20210.

If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with Civil Rights Center (see address above).

If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient).

If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your complaint within 30 days of the date on which you received the Notice of Final Action.

Inquiries May Be Addressed To:

Local Level: Tracy Hinton WIOA Equal Opportunity Officer WDBEA 300 I40 West Services Rd. Ste 4 West Memphis, Arkansas 72301 (870) 733-0601

State Level: Patrenna White Division of Workforce Services WIOA Equal Opportunity Manager P.O. Box 2981 Little Rock, AR 72203 Telephone: (501) 682-3106 ARS: 1-800-285-1131

Federal Level: Director CRC Center U.S. Department of Labor 200 Constitution Ave. N.W. Room N-4123 Washington, D.C. 20210 (202)693-6500

I certify that I have been furnished a copy of the Equal Opportunity is the Law Notice and that the Notice has been discussed in detail with me.(required) *

Yes

"Auxiliary aids and services are available upon request to individuals with disabilities." Voice: 1-800-285-1121 TDD: 1-800-285-1131

Date *

MM

DD

YYYY

Date

MM

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