Job Training Services (WIOA) Application Fill out the following form to apply for job training or work-related items assistance. Step 1 of 11 9% For which WIOA service are you applying? * RequiredCNA Job Training AssistanceCDL Job Training AssistanceLaw Enforcement Academy Job Training AssistanceMental Health TechnicianFire Fighter Academy Job Training AssistanceOther Job Training AssistanceJob Search AssistanceWork Related Items AssistanceWork ExperienceISD SanitationGED AssistancePlease check to be sure you have selected the correct WIOA Service. To participate in the service you selected, you are required to watch an orientation. Please click the link below to begin the orientation. Click here to begin the Orientation Please check to be sure you have selected the correct WIOA Service. To participate in the service you selected, you are required to watch an orientation. Please click the link below to begin the orientation. Click here to begin the Orientation After watching the orientation above, type your full name below to E-sign. By signing below you acknowledge that you watched the entire orientation video and understand its content. * Required Contact InformationName * Required First Last Social Security Number: Twist ID Birthdate - must be mm/dd/yyyy format * Required MM slash DD slash YYYY AgeSchool Status * Required In School Out of School Phone * RequiredCell PhoneEmail * Required Residence Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address different from your residence address? * Required Yes No Mailing Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ContactsBack-up ContactsPlease list at least three people with whom you're frequently in contact. Name Phone Relationship Edit Delete There are no Alternate Contacts. Add Alternate Contact Maximum number of alternate contacts reached. Qualifying QuestionsPlease tell us more about your background so that we can best determine your eligibility for services.Gender * Required Male Female You must be authorized to work in the United States to participate in this program. What is your current status? * Required U.S. Citizen Refugee/Parolee Permanent Resident Alien Other Eligible Non-Citizen INS Expiration Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Race/Ethnicity * Required American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Asian Hawaiian Native or Pacific Islander White Have you register for selective service? * Required Yes No Registration NumberAre you a veteran or currently in the military? * Required Yes No Qualified Spouse Migrant Worker Status * Required Seasonal Farm Worker Migrant Farm Worker Migrant Food Processing Worker None of the Above Do you have a criminal record? * Required Yes Yes - Misdemeanors Only No Do any of the following apply to you?Please select all that apply. Homeless Basic Skills Deficient Additional Assistance Needed Limited English Free or Reduced Lunch Out of Home Placement Runaway Youth Pregnant/Parenting Youth Foster Child Received Parent Training High Poverty Area Cultural Barrier Have you received TANF? * Required Yes No Please check any of the following that apply to your status as a TANF recipient Any 36 of Preceding 60 Months Any 30 Preceding Months Within 12 Months of Time Limit Reached Time Limit EducationPlease select your schooling status * Required In School, HS or less In School, Alternative School In School, Post HS Not Attending, HS Dropout Not Attending, HS Graduate Not Attended School last 3 months Are you attending school full- or part-time? * Required Attend School Full Time Attend School Part Time Highest Grade Completed * Required(select)No Grade123456789101112th grade, no diploma / GEDHigh School graduateGED1st yr. college, no degree2nd yr. college, no degree2nd yr. college, Associate's3rd yr. college, no degree4th yr. college, no degreeBachelor's degree or equivalent5 yr. college, Master's prog., no degree6 yr. college, Master'sDoctorateOther credential (degree, cert, etc.)Post-secondary vocational/skills credentialPost-secondary (no HS diploma or GED)Have you participated in Job Corp.? * Required Yes No Special Courses TakenPlease describe any other specialized training that you have completed (military, vocational, etc.). MilitaryMilitary Branch * Required(select)Air ForceArmyCoast GuardMarinesNational GuardNavyAre you currently active duty in the military? * Required Yes No Military Start Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Military Release Date - must be mm/dd/yyyy format MM slash DD slash YYYY Discharge Type * Required Honorable Under Honorable Other than Honorable Dishonorable Release/Retire * Required Release Retire Check any that apply to your military service: * Required Disabled Veteran Special Disabled Veteran Vietnam Service Operation Iraqi Freedom and/or Operation Enduring Freedom Campaign Badge Reserves None of the Above Public AssistanceWithin the last 6 months, list all public assistance that you have received.Please complete this section if you receive any of the following: TANF, SNAP, SSI, SNAP E&T ABAWD, SSDI, or any other public assistance currently or in the last 6 months. Type of Public Assistance HHSC Case Number HHSC Client Number Amount Received Start Date Certification Date Named or Grant? Currently Receiving? Last Payment Date Edit Delete There are no Entries. Add Entry Maximum number of entries reached. FamilyMarital Status * Required(select)SingleMarriedSeparatedDivorcedWidowedFamily StatusSelect all that apply. Parent in One-Parent Family Parent in Two-Parent Family Other Family Member Single Pregnant Female Not a Family Member Are you the head of your household with dependent children? * Required Yes No How many family members live with you? * Required(select)0123456789101112+Please list all family members who live with you. * RequiredClick the plus mark (+) to add additional rows. Add one row (and fill it in) for each family member in your household. Be sure to account for each member - the number of people listed should match the number of people selected in the dropdown above.NameRelationship to You EmploymentEmployment Status * Required(select)EmployedEmployed, but received notice of terminationNot employedNot in Labor ForceAvailable for WorkNot self-sufficientHave you worked LESS THAN 3 months in the past year? * Required Yes, I have worked less than 3 months in the past year. No, I have worked more than 3 months in the past year. Have you worked LESS THAN 3 months in the past 24 months (2 years)? * Required Yes, I have worked less than 3 months in the past 2 years. No, I have worked more than 3 months in the past 2 years. Last Job Start Date - must be mm/dd/yyyy format MM slash DD slash YYYY Last Job End Date - must be mm/dd/yyyy format MM slash DD slash YYYY Hourly WageHours Per WeekHow many weeks out of the past 26 weeks did you work? * Required(select)01234567891011121314151617181920212223242526How many months out of the past 24 months (2 years) did you work? * Required(select)0123456789101112131415161718192021222324Dislocated WorkerPlease select any that apply to your current reason for being unemployed: Planned Closure / Public Notice Terminated / Laid Off Unlikely to Return Permanent Closure / Substantial Layoff General Announcement Natural Disaster Worker Profiled and Referred Previous Self-Employment Displaced Homemaker Military Spouse Local Economic Conditions NAFTA / TAA Trade Adjustment Assistance Disability/MedicalDo you have a history of substance abuse? * Required Yes No Do you have a disability? * Required Yes No Which type of disability? * RequiredPlease check all that apply. Physical/Chronic Health Condition Physical/Mobility Impairment Mental or Psychiatric Disability Vision-related Disability Hearing-related Disability Learning Disability Cognitive/Intellectual Disability Review ApplicationPlease review the information you have submitted below for accuracy. If you need to make a change, you may go back by clicking the "Previous" button, below.{all_fields} Create Your AccountFill out the following fields to create your user account on the Workforce Solutions Panhandle Customer Portal.Username * Required Password * Required Enter Password Confirm Password Strength indicator CertificationI certify there is no intent to commit fraud. I am also aware that the information provided is true to the best of my knowledge and will be used to determine eligibility and that I am required to document the accuracy of the information and that the information is subject to external verification and may be released for such purposes. I am also aware that I am subject to immediate termination if I am found ineligible after enrollment as a result of falsifying information on the application and may be prosecuted for fraud and / or perjury.Type Your Full Name to Electronically Sign This Application * Required NameThis field is for validation purposes and should be left unchanged.
