Full Legal Name*

First Name Last Name

Please select the name of your practitioner (this should have been noted in the email you received this link in):*

Date of Birth Verification and Legally Entitled to Work in the US Verification (upload multiple if needed)*

Browse Files

ie. Driver's License, Birth Certificate, Passport, Social Security card, permanent citizenship card, etc.

Supporting Documentation for Program Eligibility (Please upload multiple documents if needed)

Browse Files

ie. Public Assistance Award Letter, Unemployment Insurance confirmation, layoff letter, layoff announcement or newspaper article of business closure, Self-Attestation (form sent by your case manager), etc.

Are you low-income?*

Yes (provide an explanation below) No

Please provide more information regarding your low-income status. (PLEASE DO NOT ENTER ANY MEDICAL INFORMATION.)

Please do not enter any medical information.

Are you legally entitled to employment within the U.S. and territories?*

Yes No

Have you been terminated, laid off, or received a notice of termination or layoff?*

Yes No

Have you been temporarily or permanently laid off as a consequence of the disaster (COVID-19)?*

Yes No

Are you long term unemployed? (Unemployed for 27 weeks or more)*

Yes No

Are you a military service member who was discharged or released from services (under conditions other than dishonorable) or has received a notice of military separation?*

Yes No

Were you unable to continue employment due to your spouse's permanent change of military station, or did you lose employment as a result of your spouse's discharge from the military?*

Yes No

Were you self-employed, but are unemployed as a result of general economic conditions in the community in which you reside? (This includes closures related to COVID-19)*

Yes No

Employment Information - Job of Dislocation*

Job Title

Business Name

Address City, State, Zip

Date of dislocation*

Date of lay off, termination, business closure, relocation (military), or quit due to military spouse relocation.

Are you a displaced homemaker? (someone who was dependent on the income of another family member and now is no longer supported by income from that family member)*

Yes No

Do you, a friend, or any member of your family have a history of opioid use? *Your answer to this question is voluntary*

Yes No

By signing below, I certify that the information provided on this document is true and accurate to the best of my knowledge and belief. I understand that such information is subject to verification and further understand that the above information, if misrepresented or incomplete, may be grounds for immediate termination from any WIOA program and/or penalties as specified by law.*

WorkSource is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. WA Relay 711


List the ages of everyone in your household:
Your Hourly Wage
Your Hours per week
Unemployment Income
Other household members earned income:
Other unearned income (ie. SSI, Food Stamps, Child support, etc.)

	Total Amount
Housing
Utilities
Childcare
Child Support
Health (Insurance, prescriptions, Copays, vitamins, etc.)
Food (including amount spent with food stamps)
Transportation (car payment, car insurance, gas, etc.)
Misc.

Please answer a few questions and upload your supporting documentation to start the WIOA Adult & Dislocated Worker Application Process: