WIOA Pre-Screening Application Form

* First Name
* Last Name
* Address (Street, City, State, Zip)
* What parish do you live in?
* Phone Number (with area code)
* Email Address (must be checked often. Check spam an junk folder as well.)
* Date of Birth (Month/Date/Year)
* Gender
* Are you of Hispanic or Latino Ethnicity?
* Race:
* Do you have a disability?
* Are you a U.S. Citizen?
If you are NOT a U.S. Citizen, are you a registered alien/refugee?
* Are you registered with Selective Service (males 18 or older)?
* Are you a Veteran?
* Are you separating or retiring from the military?
* Are you a military spouse?
If you are a Veteran what type of discharge did you receive?
* Highest grade of education completed:
* Current school status:
* Name of School(s) graduated from and years: (List out ALL schools you have graduated from and put the years you have attended.)
* Are you a drop-out?
If you ARE a drop-out, what grade and name of school dropped from:
Do you have GED/HiSET
If you do have a GED/HiSET, name of school and year:
* Are you planning to attend school?
* Are you pursuing any of the following? (check all that apply)
If you are planning to attend school, name of school planning to attend:
* Do you have a valid driver's license?
* Marital Status:
* Are you a parent, and if so, are you married or single?
* Are you pregnant?
* Have you recently divorced?
If you HAVE recently divorced, when?
* Have you recently separated from your spouse?
if you HAVE recently separated from your spouse, when?
* In order to determine need for additional services are you a victim of spousal abuse?
* Are you living in a state-recognized shelter?
If you ARE living in a state recognized shelter, how long?
* Do you have transportation to get to school or work?
* Do you live in section 8 housing?
* Are you a runaway?
* Are you homeless?
* Are you a foster child?
* Did you fail LEAP/GEE?
* Are you an offender? (This does NOT harm your chances to be deemed eligible through WIOA)
Have you ever been in any legal trouble? Please explain: (This does NOT harm your chances to be deemed eligible through WIOA)
If you have ever been in any legal trouble, have you ever/are you on probation or parole and/or had/has a PO Officer?
* Do you have a disability?
Are you a Displaced Homemaker? (Providing unpaid services to family members in the home and has been dependent on the income of another family member but is no longer supported by the income and/or is the dependent spouse of a member of the Armed Forces on active duty and whose family income is significantly reduced because of deployment, or permanent change of station (pcs).)
* Have you applied for, or are receiving, Vocational Rehabilitation Services?
* Have you applied for or are currently receiving Pell Grant?
If you ARE receiving a Pell Grant, amount:
* Have you ever been enrolled in the WIA (2000-2014) or WIOA (2015-Current) Program?
* Do you or a family member receive any of the following? (check all that apply)
If yes, how much?

A seasonal farmworker is a person who meets the following criteria:

  • during the preceding 12 months, worked at least an aggregate of 25 or more days or parts of days in which some work was performed in farm work
  • earned at least half of his or her earned income from farm work
  • not employed in farm work year-round by the same employer
* Are you a seasonal farmworker?

A migrant farmworker is a seasonal farmworker who has to travel to do the farm work and is unable to return to his or her permanent residence within the same day.

* Are you a migrant farmworker?
* What is your current employment status?
* Are you looking for work?
* Are you receiving unemployment?
Have you exhausted your unemployment benefits?
* Have you received a termination or layoff notice from your last employer?
If yes, what was your termination or layoff date?
If yes, reason for termination or layoff from last job:
Were you laid off from a plant that is TAA certified?
* By signing below: I certify the information that I have provided on this document is true and correct 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.