WIOA Pre-Screening Application Form
* First Name
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* Last Name
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If you are under the age of 18 please list your parent/guardians NAME, PHONE NUMBER, and EMAIL
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* Address (Residential - Where you live) (Street, City, State, Zip)
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* Address (Mailing) (Street, City, State, Zip)
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* What parish do you live in?
* Phone Number (with area code)
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* Email Address (must be checked often. Check spam an junk folder as well.)
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* Date of Birth (Month/Date/Year)
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* Gender
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* Are you of Hispanic or Latino Ethnicity?
* Race:
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* 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?
* Highest grade of education completed:
* Are you currently attending or in the last 6 months have you attended any school (high school or post-secondary school)?
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* Which of the following have you received?
* Did you fail LEAP/GEE?
Why are you applying for WIOA?
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* Do you have a valid driver's license?
* Are you a parent?
* Are you pregnant?
* Marital Status:
* In order to determine need for additional services are you a victim of spousal abuse?
* Are you homeless?
* Are you a runaway?
* Are you a minor in the Foster Care System or an adult who aged out of Foster Care?
* Have you ever been convicted of any crime? (This does NOT harm your chances to be deemed eligible through WIOA)
* Have you ever been in any legal trouble (including truancy with school or arrest for which charges were dropped)? Please explain: (This does NOT harm your chances to be deemed eligible through WIOA)
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* Have you ever/are you currently on probation or parole?
* 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:
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* 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?
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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

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 Seasonal Farmworker or Migrant Farmworker?
* What is your current employment status?
* Are you receiving unemployment or have you recently filed a claim for unemployment?
* Have you received a termination or layoff notice from your last employer?
If yes, what was your termination or layoff date?
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If yes, reason for termination or layoff from last job:
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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.
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