WORKSOURCE GEORGIA MOUNTAINS SCREENING

PLEASE COMPLETE ALL NECESSARY FIELDS. ONCE SUBMITTED, WORKSOURCE STAFF WILL CONTACT YOU WITH ADDITIONAL INFORMATION.

1. Applicant Information *This question is required.

First Name

Last Name

Street Address

City

State

Zip

Email Address

Phone Number (123-456-7890)

2. Age: *This question is required.

4. You must be a resident or laid off from one of the counties listed. If you were laid off, you would choose the County from which you were laid off. If you were not laid off and do not see your county listed, call 770-538-2722 for assistance.

Example: you live in Gwinnett but were laid off in Hall; select Hall County below and proceed with the application. *This question is required.

4. Do any of these situations apply to you? *This question is required.

Pregnant or parenting
Does not have a High School Diploma
Is subject to the Adult or Juvenile justice system
Homeless or runaway
Is/was in foster care or has aged out of the foster care system
Has a documented disability, including but not limited to an IEP or 504 plan
Not applicable

4. If you're 24 or younger, do you live at home? Do your parents claim you on their taxes? *This question is required.

4. Have you ever used WIOA funding before? *This question is required.

5. Are you a veteran? *This question is required.

8. If married, does your spouse work? *This question is required.

8. Please explain your housing situation (ie: who lives in your house): *This question is required.

8. Has your household received any of these benefits in the last six months? Check all that apply.

9. Are you currently working? *This question is required.

10. Full-time, part-time, PRN? *This question is required.

10. Please enter your current or most recent employer. *This question is required.

Employer Name

Employer City & State

City, State

Employment Start Date (mm/dd/yyyy)

Employment End Date (mm/dd/yyyy)- Note: If working, enter - currently employed

Job Title

Rate of Pay (ex. $15/hr or $240/wk)

Hours Worked Per Week

If Other, please explain why you no longer work for this employer, OR enter N/A.

10. Highest Level of Education Completed? *This question is required.

11. Are you currently in school? *This question is required.

12. If YES, what school?

12. When will you graduate? This question requires a valid date format of MM/DD/YYYY.

Graduation Date: calendar

12. What program are you taking? *This question is required.

PROGRAM

12. What school are you attending? *This question is required.

School

12. What school are you interested in attending?

12. What program are you interested in attending? I.E. Welding, Nursing, CDL, ETC.

12. Is your GPA a 2.0 or greater?

12. What program was your degree or diploma in?

12. What year did you graduate?

12. Signature

Clear

Signature of

WORKSOURCE GEORGIA MOUNTAINS SCREENING

WIOA PRE-SCREENING TOOL