Applicant Information

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Applicant Information

First Name	Middle Initial
Last Name	Street Address
City	State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip	County
Phone 1ext.	Phone 2ext.
Phone 1 Description (home, cell, work, etc.)	Phone 2 Description (home, cell, work, etc.)
Email Address	How did you hear about us?

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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.

Contact 1 First Name	Contact 1 Last Name
Contact 1 Relationship	Contact 1 Phoneext.
Contact 2 First Name	Contact 2 Last Name
Contact 2 Relationship	Contact 2 Phoneext.

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Private Information

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Private Information

Social Security #

Birthdate

Hispanic

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Hispanic

Yes

No

Ethnicity

Ethnicity(Select an Answer) American Indian/Alaskan Native Asian Black White Hawaiian/Pacific Islander Prefer Not to Answer

Gender

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Gender

Male

Female

Authorization to Work in the U.S.

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Authorization to Work in the U.S.

U.S. Citizen

Registered Alien/Refugee

Males ONLY: Selective Service Compliant?

Males ONLY: Selective Service Compliant?

Yes

No

NA

Disability Status
Do you have a Disability Affecting Employment?

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Disability Status Do you have a Disability Affecting Employment?

Yes

No

If yes, please describe

If yes, please describe

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Veteran Status

Are you a Military Veteran?

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Veteran Status Are you a Military Veteran?

Yes

No

Are you an Illinois Veteran?

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Are you an Illinois Veteran?

Yes

No

If yes, list Branch of Service

If yes, list Branch of Service

Service Dates

Service Dates

From:

To:

Nature of Discharge

Nature of Discharge (Select an Answer) Dishonorable Honorable Service-Connected Disability Less Than Honorable

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Education Status

Attained High School Diploma?

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Education Status Attained High School Diploma?

Yes

No

GED Completed?

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GED Completed?

Yes

No

Highest Grade Completed

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Highest Grade Completed (Select an Answer) No School 1st - 5th Grade 6th - 8th Grade High School Freshman High School Sophomore High School Junior High School Senior College Freshman College Sophomore College Junior College Senior Associate Degree Bachelor's Degree Master's Degree Doctorate Degree

 

College degree area(s) of study

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Employment Characteristics

Current Employment Status

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Employment Characteristics Current Employment Status

Employed

Employed, but received notice of termination/separation

Not in labor force

Unemployed

If unemployed, how many weeks since your last employment?

Unemployment Benefit Status

Unemployment Benefit Status

Receiving benefits	Exhausted benefits
Not eligible / not determined	Eligible, but not receiving

Employment Goal

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Employment Goal

Are you looking for full-time or part-time work?

In what career/job/field would you like to work?

Describe your current situation - Check all that apply

Describe your current situation - Check all that apply

Need immediate work	Job search assistance
Training for new skills	Child care issues
Transportation issues	Financial problems
Special Ed. student	Want/need GED
English as 2nd language	Bilingual

Interested in Training?

Interested in Training?

School based?

Internship/Work Experience?

On-the-Job Training?

Sector Area of Interest - Check all that apply

Sector Area of Interest - Check all that apply

Business, Management, Professional	Information Technology
Office Administration, Clerical	Healthcare, Medical
Manufacturing	Transportation, Warehouse, Logistics

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Work History

List 10 years of employment, most recent first.

Most Current Employer Information

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Most Current Employer Information

Employer Name

Street Address

City

State

Zip

Type of Industry

Employment Start Date

Employment End Date

Hours per Week

Ending Wage (specify per hour/week/month/year)

Occupation / Job Title

Current Status

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Current Status

Fired	Laid Off
Quit	Still Employed
Still Employed, Layoff Pending

Duties, skills, responsibilities, equipment used:

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Duties, skills, responsibilities, equipment used:

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Next Former Employer Information (if needed)

Next Former Employer Information (if needed)

Employer Name

Street Address

City

State

Zip

Type of Industry

Employment Start Date

Employment End Date

Hours per Week

Ending Wage (specify per hour/week/month/year)

Occupation / Job Title

Current Status

Current Status

Fired	Laid Off
Quit	Still Employed
Still Employed, Layoff Pending

Duties, skills, responsibilities, equipment used:

Duties, skills, responsibilities, equipment used:

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Next Former Employer Information (if needed)

Next Former Employer Information (if needed)

Employer Name

Street Address

City

State

Zip

Type of Industry

Employment Start Date

Employment End Date

Hours per Week

Ending Wage (specify per hour/week/month/year)

Occupation / Job Title

Current Status

Current Status

Fired	Laid Off
Quit	Still Employed
Still Employed, Layoff Pending

Duties, skills, responsibilities, equipment used:

Duties, skills, responsibilities, equipment used:

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Characteristics and Barriers

Check all that apply

Characteristics and Barriers Check all that apply

Drug/alcohol dependency	Making realistic career decisions
Limited English proficiency	Dealing with parole/probation
Offender - felony	Overcoming physical handicaps
Offender - misdemeanor	Overcoming depression/discouragement
Homeless	Experiencing legal issues
Supporting myself during job search	Getting job-related training

Youth Barriers

Check all that apply if you are age 24 or younger.

Youth Barriers Check all that apply if you are age 24 or younger.

Pregnant / Parenting Youth	Foster Child
Runaway Youth	Youth Aged Out of Foster Care
Youth Needing Assistance	Subject to Juvenile or Adult Justice System
Learning Disability	Physical Disability
Eligible to Receive Free or Reduced Price Lunch	English Language Learner
Within age of Compulsory School Attendance, but not attending School this quarter

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Public Assistance

Check all that apply

Public Assistance Check all that apply

Transitional Assistance	Refugee Help
Supplemental Security	Social Security Disability
SNAP (Food Stamps)	TANF

 

If receiving TANF assistance, for how many months?

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Family Characteristics

Check only one

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Family Characteristics Check only one

Parent in a one-parent family	Parent in a two-parent family
Not a family member / Single or living alone	Other family member / Married or living with others

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	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).
2	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).
3	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).
4	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).
5	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).
6	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).
7	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).
8	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).	Please list ALL members of the HOUSEHOLD (List yourself first).

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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 and Opportunity Act (WIOA) 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.

Please allow 7 to 10 business days for your application to be reviewed by our staff.

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I have read and agree to the Notice of Certification

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2. Email Address

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