BEFORE YOU START ASKING US IF WE GOT YOUR APPLICATION:
After you click the ‘Submit’ button at the bottom of this page, you will see “Thank you for your worksheet. It has been sent and will be processed.” inside a green box, if your form made it to our database. If you see the green box, we received your application and will be processing it. Take a screen shot of your green box if you feel the need.
If you got a red box instead, that means you’re missing some information in one or more of the boxes. Scroll back up and fill in the empty boxes. Then click ‘Submit’ button at the bottom of the page again, and look for the green box.
____________________________________________________________ 1. CONTACT INFORMATION
First Name
Middle Name
Last Name
Date of Birth
Social Security #
Program Start Date
Email Address
Address
Apartment #
City
State
Zip Code
Cell Phone
Work Phone
____________________________________________________________ 2. GENDER
MaleFemaleX ‘X’ includes Trans, Non-Binary, Two-Spirit, and Binary people and people who don’t want to disclose their gender identity
____________________________________________________________ 3. RACE/ETHNIC IDENTITY
Native American or Alaskan NativeAfrican American/African/Afro-CaribbeanLatino or HispanicWhite (not Latino/a)Other If Other, please describe
Country of Birth
Date of US Settlement
Native Language
Immigrant? YesNo
Refugee? YesNo
____________________________________________________________ 4. Employment Status
Employed Full-TimeEmployed Part-TimeUnemployedNot available for employmentSelf-employedReceived a 1099 Form for work If unemployed, how long Years: Months:
Employer’s Name
Job Title
Hourly Rate of Pay
Average hours worked weekly
Work Location
____________________________________________________________ 5. MARITAL STATUS
SingleMarriedWidowedSeparatedDivorced
Number of Adults in Household
Number of Children (under 18 y.o.) in Household
Average Household Income
0 – $14,999$15,000 – $24,999$25,000 – $34,999$35,000 – $44,999$45,000 – $54,999$55,000 – $64,999$65,000 – $74,999> $75,000
Are you a Veteran? YesNo
____________________________________________________________ 6. PUBLIC ASSISTANCE
Not received Public AssistanceSNAP (EBT card)MEDICAIDSection 8 AssistanceOld-aged AssistanceSupplemental Security Income (SSI)Social Security Disability (SSD)Safety NetAid to the Blind or Totally DisabledOther If Other, please specify
Case Number
Are you collecting Unemployment Insurance Benefit? YesNo
____________________________________________________________ 7. EDUCATIONAL BACKGROUND
Less than 12 GradeHigh School DiplomaPost Secondary EducationOther If Other, please specify
Credential (Certifications and Licenses) achieved in the US:
____________________________________________________________ 8. UNION AFFILIATION
Are you a Union Member or Family of a Union Member? YesNo
If Yes, are you a MemberFamily of a Member
Union Affiliation
Local Number
____________________________________________________________ 9. School Aged Children
Are you the parent or guardian of children under the age of 21? YesNo
If yes, are you a single parent? YesNo
If yes, enter number of children at each level Pre-school Elementary Junior High School High School Post-Secondary
____________________________________________________________ 10. POPULATION CATEGORIES
HomelessIn Correctional FacilityOther InstitutionalizedHigh School Graduate or EquivalentDisplaced HomemakersHead of HouseholdDisabledEnrolled in Other Education/TrainingVeteransDislocated WorkersEmployed at 200% of Poverty LevelLow IncomeNYCHA ResidentLearning DisabledNon Native English SpeakerOther If Other, please describe
____________________________________________________________ 11. REFERRAL SOURCE
Workers UnionOther If Other, please describe
____________________________________________________________ 12. WORKER GOALS
Obtain a JobRetain Current JobImprove Current JobEnter TrainingEnter an Apprenticeship ProgramEarn High School DiplomaEnter Post-Secondary EducationImprove Basic Literacy SkillsImprove English Literacy SkillsOther If Other, please describe
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