|Please answer the questions below as accurately as possible.
Complete all sections of this form. The information provided will be used to determine your eligibility for services under this program.
I. APPLICANT INFORMATION
Last Name First Name Middle Initial
Last 4 Digits of SS# Date of Birth Age
CityState Zip Code
County Phone Mobile Email
Number of dependents Age(s) of Children
Check any of the following that apply to you:
School Dropout Parent or Pregnant Disabled Offender
Foster Child Homeless or Runaway
II. INCOME INFORMATION
Please specify the # of family members living in your household
AND check your approximate
annual gross family income:
$1 - $10,830
$10,831 - $14,570
$14,571 - $18,310
$18,311 - $22,500
$22,501 - $26,556
$26,557 - $31,058
$31,059 - $35,560
$35,561 - $40,062
What is your family's approximate gross monthly income?
With whom do you live? (Check all that apply)
Alone Parents Child(ren) Spouse
Indicate the monthly amount your household receives from each of the
FI/TANF Food Stamps ABC Child Support
SSI Unemployment VA Benefit Other
III. EDUCATIONAL INFORMATION
What is your educational or career goal?
Highest education level:
List vocational certificates:
Highest grade completed if you did not graduate from high school?
Are you currently attending a GED prep course?
Have you attended or are you currently attending college/training?
If "Yes" list name of school
Dates of Enrollment List Program
If you did not complete it, please list reason:
Have you previously participated in a WIA program?
If yes, please list when, where and the name of your case manager/consultant:
IV. EMPLOYMENT INFORMATION
Last Employer Address
City/State/Zip Code Phone
Hourly Wage Hours Per Week Start Date End Date
Reason for leaving
Previous Employer Address
V. ALTERNATE CONTACT INFORMATION
(Please provide information on someone not in your household)
Hourly Wage Hours Per Week
Reason for leaving
VI. PERSONAL STATEMENT
Please write a brief statement indicating why you want to participant in
the Workforce Investment Act (WIA) Youth Program. Include what you hope to gain through your
participation with the program.
VII. SIGNATURE OF CERTIFICATION
By pressing the "Submit" button below, you are stating that you have read and
agreed to all the following statements.
- I understand that the completion of the application
does not guarantee acceptance into the WIA Youth Program.
- I certify that the information provided on this
application is true and correct to the best of my knowledge.
- I understand that ANY information provided that is
falsified will disqualify me from participating in the WIA Youth Program at Midlands Technical College.
- I authorize the College to release my educational,
academic, financial, and other pertinent information to the WIA staff.
- I understand that the information provided on this
application will be held in strict confidence by WIA/College staff.