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Workforce Innovation and Opportunity Act (WIOA) Application

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Applicant Information

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Applicant Information

Emergency Contacts

Please list two people (not living with you) for emergency contacts only.

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Emergency Contacts Please list two people (not living with you) for emergency contacts only.

Private Information

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Private Information
Hispanic
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Hispanic
Ethnicity
Gender
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Gender
Authorization to Work in the U.S.
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Authorization to Work in the U.S.
Males ONLY: Selective Service Compliant?
Males ONLY: Selective Service Compliant?
Disability Status
Do you have a Disability Affecting Employment?
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Disability Status Do you have a Disability Affecting Employment?
If yes, please describe

Veteran Status

Are you a Military Veteran?

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Veteran Status Are you a Military Veteran?
Are you an Illinois Veteran?
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Are you an Illinois Veteran?
If yes, list Branch of Service
Service Dates
Service Dates
Nature of Discharge

Education Status

Attained High School Diploma?

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Education Status Attained High School Diploma?
GED Completed?
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GED Completed?
Highest Grade Completed
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Employment Characteristics

Current Employment Status

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Employment Characteristics Current Employment Status

Unemployment Benefit Status
Unemployment Benefit Status
Employment Goal
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Employment Goal
Describe your current situation - Check all that apply
Describe your current situation - Check all that apply
Interested in Training?
Interested in Training?
Sector Area of Interest - Check all that apply
Sector Area of Interest - Check all that apply

Work History

List 10 years of employment, most recent first.

Most Current Employer Information
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Most Current Employer Information
Current Status
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Current Status
Duties, skills, responsibilities, equipment used:
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Next Former Employer Information (if needed)
Next Former Employer Information (if needed)
Current Status
Current Status
Duties, skills, responsibilities, equipment used:

Next Former Employer Information (if needed)
Next Former Employer Information (if needed)
Current Status
Current Status
Duties, skills, responsibilities, equipment used:

Characteristics and Barriers

Check all that apply

Characteristics and Barriers Check all that apply

Public Assistance

Check all that apply

Public Assistance Check all that apply
 

Family Characteristics

Check only one

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Family Characteristics Check only one
Please list ALL members of the HOUSEHOLD (List yourself first).
Please list ALL members of the HOUSEHOLD (List yourself first).
Name Relationship Age Has Income? Income Tax Dependent?
1
2
3
4
5
6
7
8

Read the following

Notice of Certification:  I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud.  I have been advised that this information will be entered into a computerized information system and may be shared with other agencies for the purpose of administering programs of these agencies.  I have the right to inspect this information and initiate appropriate corrections through the administering agency.  I agree to participate in the Workforce Investment Act (WIA) post-training follow-up.  I hereby acknowledge that if the information relating to eligibility determination and/or post-training follow-up (employment information) requires verification/documentation, I authorize others to release the information required.

McHenry County is an equal opportunity employer/program Auxiliary aids and services are available upon request to individuals with disabilities.

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