WIOA Intake Form
Lumbee Regional Development Association
What program are you applying for?
*
Classroom Training Program (I want to take classes)
Work Experience Program (I am looking or applying for a job.)
If you are applying for Work Experience select the applicable option below. (Skip these questions if you are applying for classroom training).
I know the job I want to apply for.
I am applying for any open position.
If you know the job you are applying for, list the job title and location below.
If you do not have a specific job you are applying for, what type of work are you seeking?
Personal Data
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Social Security Number
Phone Number
*
Email Address
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Birthday
*
-
Month
-
Day
Year
Date
Age
*
Race ( Check all that apply)
*
American Indian
White
Black
Hispanic
Asian
Other
Sex
*
Male
Female
Offender
*
Yes
No
Are you a...(Check all that apply)
*
Veteran
Spouse of a veteran
Disabled
None of the above
Marital Status
*
Married
Single
Divorced
Separated
If married, Spouses name
Spouse phone number
Parent's Name ( List both father and mother, if applicable)
Parent's phone number (List both, if applicable)
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Financial Information
Family Income (last 6 months)
*
Select one
*
Farm
Non-Farm
Family Size
*
Do you receive public assistance?
*
Yes
No
If receiving public assistance, what type?
*
Do you have a Drivers License?
*
Yes
No
Do you have reliable transportation?
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Yes
No
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Educational Information
Highest Grade Completed
*
Elementary School(s) Attended
*
High School Attended
*
College or Technical Schools Attended
*
Do you have a degree? If, so what kind.
*
Do you have military training?
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Yes
No
Are you currently enrolled in any type of school?
*
Yes
No
If yes, what type?
Adult Basic Education
Technical School
College
Other
If enrolled, name of school
If enrolled, area of concentration
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Work History
Name of Employer
Job Title
Dates of Employment (ex. 1-1-22 to 2-22-22)
Reason for leaving
Name of Employer
Job Title
Dates of Employment (ex. 1-1-22 to 2-22-22)
Reason for leaving
Have you ever worked or received services for WIOA or JTPA before?
*
Yes
No
If yes, please list sponsor / component?
If yes, what was the length of participation? (ex: 1-1-22 to 2-2-22)
What skills were developed? ( Training and/or work experience)
Please list vocational interests.
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Office Use Only (Contact Notes)
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I, hereby attest that the information in this intake application is accurate to the best of my knowledge.
Intake form will be kept on active file for a period of 45 days.
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