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Click here or scroll down to respond to this candidateCandidate's Name
Auxiliary Aids & Services Available to Individuals with Disabilities Please complete the following form to the best of your abilities. PART I: APPLICANT INFORMATIONApplicant Name:First MI LastApplication Date:Birth Date: Social Security Number- -Gender:Male Female Do Not Wish to AnswerRace:African American American Indian/Alaskan Native Asian WhiteHawaiian/Pacific Islander I do not wish to answer Are you of Hispanic or Latino Origin?Yes No I do not wish to answerWhat is your primarylanguage if NOT English:Primary Phone Phone Type:Mobile Work Home OtherEmail: Contact Preference:Phone EmailResidential Address: City: State: Zip Code: County of Residence: Mailing Address Check here to use residential address City State: Zip Code: County Alternate Contact: Relationship Phone NumberAre you legally authorized to work in the United States? Yes No Are you a United States Citizen? Citizen of US or US Territory U.S Permanent ResidentAlien/Refugee Lawfully Admitted to the US None of the Above If Alien/Refugee Alien Card #: Exp. Date:What is your current employment status? Working Fulltime Working Part-time Not Working Never Worked Have you registered for the Selective Service (www.sss.gov)?(Males born on or after 1/1/1960, ONLY) Yes No NA Documented Exemption Do you have a disability? Yes NoAre you currently in the military, a veteran or a spouse of a member of the armed forces who is on active duty or a veteran?Yes NoHave you previously enrolled in WIOA funded training? Yes No If YES, please complete the following:Name of School attended: Name of Training Program: Completion Date: Did you complete the training? If no, why not: Yes No Did you find a job after you completed the training? Yes No If YES, was the job related to the training you received? Name of Employer: Position: Dates of Employment: (mm/dd/yy) From ToWhat are your future employment goals?WorkSource Metro AtlantaWIOA Eligibility ApplicationIf Yes, do you need additional support? Yes No Page 1john D Williams 10/16/202309/11/PHONE NUMBER AVAILABLE nPHONE NUMBER AVAILABLE EMAIL AVAILABLE4116 panola lake circle lithiona ga 30038 dekalb4116 panola lake circle lithiona ga 30038 dekalbjohn williams father PHONE NUMBER AVAILABLEgagadekalbnCandidate's Name
Auxiliary Aids & Services Available to Individuals with Disabilities PART II: ELIGIBLITYDISLOCATED WORKER CategoryHave you received notice of termination or layoff from your last job or received documentation that you are separating from the military? Yes NoIf YES, please provide the date of termination or separation(mm/dd/yy)If YES, please provide the information of your previous employer Employer Name Employer CountyAddress City State Zip CodeADULT CategoryIn the past six months, have you or anyone in your family received the following public assistance: Temporary Assistance for Needy Families (TANF) Yes No Supplemental Nutrition Assistance Program (SNAP) Yes No Supplemental Security Disability Income (SSDI) Yes No Supplemental Security Income (SSI) Yes NoAny other forms of public support? Yes NoExplain:PART III: FAMILY COMPOSITION OF INCOMEFamily Composition: List each family member (spouse and dependents) living in the home Names of Family MembersIncluding ApplicantRelationship AgeSocial Security #(over 14 years of age)Total Gross Income(Six Months Prior to Application)APPLICANT/SELFList other sources of financial support andamounts received:EXAMPLES: child support, unemployment, Social Security 123Total # inHousehold:Total HouseholdIncomeNOTE: Falsification of data on this form is a crime against Federal and State laws and is punishable by a fine or imprisonment or both and will require repayment of any monies paid to or on behalf of the applicant while in training. Page 2Are you currently receiving unemployment benefits? Yes No john williams PHONE NUMBER AVAILABLE,000N/AN/AN/ACandidate's Name
Auxiliary Aids & Services Available to Individuals with Disabilities Please complete the following form to the best of your abilities Are you currently in school? YES NOIf YES, Name of School: Program:Highest School Grade Completed: None Grade School Middle School 10th 11th 12th High school diploma or equivalent received (GED) YES NO Highest Qualification Level Completed:Do NOT complete for education levelsof less than high school or high schoolequivalency diplomaCertificate of Attendance/Completion (Disabled Individuals)High School Equivalency DiplomaHigh School Diploma1 Year at College or a Technical or Vocational School2 Years at College or Technical or Vocational School3 Years at a College or Technical or Vocational SchoolVocational School CertificateAssociates DegreeBachelors DegreeMasters DegreeDoctorate DegreeSpecialized DegreeCourse of Study Issuing InstitutionDo you possesses any certifications or licenses? YES NO If YES, list below:1Certificate/License Issuing OrganizationCompletion Date: State Country:2Certificate/LicenseCompletion Date: State Country:3Certificate/LicenseCompletion Date: State Country:Issuing OrganizationIssuing OrganizationPART IV: EDUCATION HISTORYPage 3EstimatedCompletion Date:nnnncomputer information Dekalb collegenCandidate's Name
Auxiliary Aids & Services Available to Individuals with Disabilities APPLICANT ATTESTATION:The information I have provided on pages 1-4 of this application are true. I understand that any false or misrepresented information may adversely affect my eligibility for services or disqualify me from receiving assistance. Applicant Signature DateApplicant Printed NamePART V: WORK EXPERIENCEPlease list your work experience for the past 3 jobs your most recent job held. Name of Employer: Occupation Title: Type:Full Time Part-TimeEmployment Dates: (mm/dd/yy)From ToWage/Salary$City County StateReason for leaving job (be specific):List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company: Name of Employer: Occupation Title: Type:Full Time Part-TimeEmployment Dates: (mm/dd/yy)From ToWage/Salary$City County StateReason for leaving job (be specific):List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company: Name of Employer: Occupation Title: Type:Full Time Part-TimeEmployment Dates: (mm/dd/yy)From ToWage/Salary$City County StateReason for leaving job (be specific):List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company: Page 4Cabniet and Counter Tops Cabin delivery njuly September 17 conyers conyers Gacomplication of bodyDomino Manager Manager/driver nFeb September 12 lithiona Dekalb Ga |
