DW Eligibility Checklist
Applicant Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Categories of Dislocation
*
Make One Selection:
Category 1: General Dislocation
1
Category 2: Plant Closure/Substantial Layoff
2
Category 3: Self-Employed
3
Category 4: Displaced Homemaker
4
Category 5: Dislocating/Separating Service Members
5
Category 6: Spouses of Military Service Members
6
Basic Eligibility
*
Criteria met? Y/N
Documentation Attached? Y/N
DOB Verification (can be under 18)
Yes
No
N/A
Yes
No
N/A
Selective Service (if applicable)
Yes
No
N/A
Yes
No
N/A
Legally Entitled to work in the U.S.
Yes
No
N/A
Yes
No
N/A
Initial Review of Eligibility
*
Yes
No
Practitioner Name
*
First Name
Last Name
Practitioner Signature
*
Date
*
-
Month
-
Day
Year
Date
Validation of Eligibility:
Eligible
Not Eligible
Approver Name
First Name
Last Name
Explanation of Denial:
Approver Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: