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Job Training Services (WIOA) Application

Fill out the following form to apply for job training or work-related items assistance.

Step 1 of 11

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For which WIOA service are you applying? * Required
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
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 Information
Name * Required
First Last
Social Security Number:
Twist ID
Birthdate - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Age
School Status * Required
- In School
- Out of School
Phone * Required
Cell Phone
Email * Required
Residence Address * Required
Street Address Address Line 2 City State ZIP Code
Is your mailing address different from your residence address? * Required
- Yes
- No
Mailing Address * Required
Street Address Address Line 2 City State ZIP Code
Contacts

Back-up Contacts

Please list at least three people with whom you're frequently in contact.

Name	Phone	Relationship
			Edit Delete
There are no Alternate Contacts.

Maximum number of alternate contacts reached.

Qualifying Questions
Please 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
Date Format: 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 Number
Are 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

Education
Please 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
Have you participated in Job Corp.? * Required
- Yes
- No
Special Courses Taken
Please describe any other specialized training that you have completed (military, vocational, etc.).

Military
Military Branch * Required
Are you currently active duty in the military? * Required
- Yes
- No
Military Start Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Military Release Date - must be mm/dd/yyyy format
Date 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 Assistance

Within 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.

Maximum number of entries reached.

Family
Marital Status * Required
Family Status
Select 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
Please list all family members who live with you. * Required
Click 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.
Name Relationship to You

Employment
Employment Status * Required
Have 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
Date Format: MM slash DD slash YYYY
Last Job End Date - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Hourly Wage
Hours Per Week
How many weeks out of the past 26 weeks did you work? * Required
How many months out of the past 24 months (2 years) did you work? * Required
Dislocated Worker
Please 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/Medical
Do you have a history of substance abuse? * Required
- Yes
- No
Do you have a disability? * Required
- Yes
- No
Which type of disability? * Required
Please 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 Application
Please 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.
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Create Your Account
Fill out the following fields to create your user account on the Workforce Solutions Panhandle Customer Portal.
Username * Required
Password * Required
Enter Password Confirm Password

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Certification
I 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
Comments
This field is for validation purposes and should be left unchanged.

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Name * Required
First Last
Phone * Required
Relationship * Required

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Type of Public Assistance * Required
HHSC Case Number
HHSC Client Number
Amount Received * Required
Start Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Certification Date - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Named or Grant?
- Yes
- No
Currently Receiving? * Required
- Yes
- No
Last Payment Date - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.