Equal Opportunity Employer/Program

Auxiliary Aids & Services Available to Individuals with Disabilities Please complete the following form to the best of your abilities. PART I: APPLICANT INFORMATION

Applicant Name:

First MI Last

Application Date:

Birth Date: Social Security Number

- -

Gender:

Male Female Do Not Wish to Answer

Race:

African American American Indian/Alaskan Native Asian White

Hawaiian/Pacific Islander I do not wish to answer Are you of Hispanic or Latino Origin?

Yes No I do not wish to answer

What is your primary

language if NOT English:

Primary Phone Phone Type:

Mobile Work Home Other

Email: Contact Preference:

Phone Email

Residential Address: City: State: Zip Code: County of Residence: Mailing Address Check here to use residential address City State: Zip Code: County Alternate Contact: Relationship Phone Number

Are you legally authorized to work in the United States? Yes No Are you a United States Citizen? Citizen of US or US Territory U.S Permanent Resident

Alien/Refugee Lawfully Admitted to the US None of the Above If Alien/Refugee Alien Card #: Exp. Date:

What is your current employment status? Working Fulltime Working Part-time Not Working Never Worked Have you registered for the Selective Service (www.sss.gov)?

(Males born on or after 1/1/1960, ONLY) Yes No NA Documented Exemption Do you have a disability? Yes No

Are you currently in the military, a veteran or a spouse of a member of the armed forces who is on active duty or a veteran?

Yes No

Have you previously enrolled in WIOA funded training? Yes No If YES, please complete the following:

Name of School attended: Name of Training Program: Completion Date: Did you complete the training? If no, why not: Yes No Did you find a job after you completed the training? Yes No If YES, was the job related to the training you received? Name of Employer: Position: Dates of Employment: (mm/dd/yy) From To

What are your future employment goals?

WorkSource Metro Atlanta

WIOA Eligibility Application

If Yes, do you need additional support? Yes No Page 1

john D Williams 10/16/2023

09/11/197*-***-**-**** n

404-***-**** ad2a27@r.postjobfree.com

4116 panola lake circle lithiona ga 30038 dekalb

4116 panola lake circle lithiona ga 30038 dekalb

john williams father 770-***-****

ga

ga

dekalb

n

Equal Opportunity Employer/Program

Auxiliary Aids & Services Available to Individuals with Disabilities PART II: ELIGIBLITY

DISLOCATED WORKER Category

Have you received notice of termination or layoff from your last job or received documentation that you are separating from the military? Yes No

If YES, please provide the date of termination or separation

(mm/dd/yy)

If YES, please provide the information of your previous employer Employer Name Employer County

Address City State Zip Code

ADULT Category

In the past six months, have you or anyone in your family received the following public assistance: Temporary Assistance for Needy Families (TANF) Yes No Supplemental Nutrition Assistance Program (SNAP) Yes No Supplemental Security Disability Income (SSDI) Yes No Supplemental Security Income (SSI) Yes No

Any other forms of public support? Yes No

Explain:

PART III: FAMILY COMPOSITION OF INCOME

Family Composition: List each family member (spouse and dependents) living in the home Names of Family Members

Including Applicant

Relationship Age

Social Security #

(over 14 years of age)

Total Gross Income

(Six Months Prior to Application)

APPLICANT/SELF

List other sources of financial support and

amounts received:

EXAMPLES: child support, unemployment, Social Security 1

2

3

Total # in

Household:

Total Household

Income

NOTE: Falsification of data on this form is a crime against Federal and State laws and is punishable by a fine or imprisonment or both and will require repayment of any monies paid to or on behalf of the applicant while in training. Page 2

Are you currently receiving unemployment benefits? Yes No john williams 48-589****** 5,000

N/A

N/A

N/A

Equal Opportunity Employer/Program

Auxiliary Aids & Services Available to Individuals with Disabilities Please complete the following form to the best of your abilities Are you currently in school? YES NO

If YES, Name of School: Program:

Highest School Grade Completed: None Grade School Middle School 10th 11th 12th High school diploma or equivalent received (GED) YES NO Highest Qualification Level Completed:

Do NOT complete for education levels

of less than high school or high school

equivalency diploma

Certificate of Attendance/Completion (Disabled Individuals)

High School Equivalency Diploma

High School Diploma

1 Year at College or a Technical or Vocational School

2 Years at College or Technical or Vocational School

3 Years at a College or Technical or Vocational School

Vocational School Certificate

Associates Degree

Bachelor’s Degree

Master’s Degree

Doctorate Degree

Specialized Degree

Course of Study Issuing Institution

Do you possesses any certifications or licenses? YES NO If YES, list below:

1

Certificate/License Issuing Organization

Completion Date: State Country:

2

Certificate/License

Completion Date: State Country:

3

Certificate/License

Completion Date: State Country:

Issuing Organization

Issuing Organization

PART IV: EDUCATION HISTORY

Page 3

Estimated

Completion Date:

n

n

n

n

computer information Dekalb college

n

Equal Opportunity Employer/Program

Auxiliary Aids & Services Available to Individuals with Disabilities APPLICANT ATTESTATION:

The information I have provided on pages 1-4 of this application are true. I understand that any false or misrepresented information may adversely affect my eligibility for services or disqualify me from receiving assistance. Applicant Signature Date

Applicant Printed Name

PART V: WORK EXPERIENCE

Please list your work experience for the past 3 jobs your most recent job held. Name of Employer: Occupation Title: Type:

Full Time Part-Time

Employment Dates: (mm/dd/yy)

From To

Wage/Salary

$

City County State

Reason for leaving job (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company: Name of Employer: Occupation Title: Type:

Full Time Part-Time

Employment Dates: (mm/dd/yy)

From To

Wage/Salary

$

City County State

Reason for leaving job (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company: Name of Employer: Occupation Title: Type:

Full Time Part-Time

Employment Dates: (mm/dd/yy)

From To

Wage/Salary

$

City County State

Reason for leaving job (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company: Page 4

Cabniet and Counter Tops Cabin delivery n

july September 17 conyers conyers Ga

complication of body

Domino Manager Manager/driver n

Feb September 12 lithiona Dekalb Ga

Contact this candidate