Pre-Application Screening Form

* Name (First and Last)
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* Address (Street, City, State, Zip)
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* What Parish do you live in?
* Phone Number (with area code)
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* Email
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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?
If you are a Veteran what type of discharge did you receive?
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* Highest grade of education completed:
* Current school status:
* Name of School (s) graduated from and years:
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* Are you a drop-out?
If you ARE a drop-out, what grade and name of school dropped from:
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Do you have a GED/HiSET?
If you do have a GED/HiSET, name of school and year:
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* Are you planning to attend school?
* Are you perusing any of the following?
If you are planning to attend school, name of school planning to attend:
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If you are planning to attend school, what course/major and what is your planned start date?
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* Do you have a valid driver's license?
* 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?
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* Have you recently separated from your spouse?
If you HAVE recently separated from your spouse, when?
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* 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?
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* 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:
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* Have you ever been enrolled in the WIA or WIOA Program (2000-2014)?
* Do you or a family member receive any of the following? (check all that apply)
If yes, how much?
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* 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?
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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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