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)
* 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:
* 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?
* Do you have a disability?
* 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.