Personal Information
Last Name, First Name, MI
/ Suffix / Date of Birth / SSNCitizenship / Gender / Race: / Ethnicity
q U.S. Citizen
q Eligible Non-Citizen
q Non-Citizen / q M
q F / q American Indian/Alaskan Native
q Asian
q Black or African American (Non-Hispanic)
q Hawaiian Native or other Pacific Islander
q White
q Other / q Hispanic/Latino
q Not Hispanic/Latino
Address & Contact Information
Type of Address: / q Home / q Mailing / q Work / Contact Information:
Home Phone / Message
Street Number / Street Name / Work Phone: / Fax
County: / q New Castle / q Kent / q Sussex / Cellular / Pager
Apartment In Wilmington City Limits: _____Yes _____No
City / State / Zip Code
Eligibility Screening Information
/Registered for Selective Services?
/ q Yes / q NoExemption / q Currently incarcerated or otherwise institutionalized / q Honorably Discharged Veteran
q Currently student at a U.S. Military Service Academy / q No Exemption
q Currently on Active Duty in U.S. Armed Forces / q Obviously Handicapped
q Exception authorized by Selective Service Registration Status
NOTE: Federal Law requires that men born on or after 01/01/1960 must register as required by the Military Services Act within 30 days of their 18th birthday.
Eligibility Determination
Family Size______/ Includable family income for the last six (6) months $______/ Single Parent: _____Yes ______NoHousehold Income
Does Applicant of family receive ANY of the following (check all that apply) / Barriers:
Mark the applicable box(es) to indicate barriers to employment and/or training the Applicant has (check all the apply)
q Supplemental Security Income (SSI) / q Limited English Proficiency / q Mental or Physical Disability
q Welfare Assistance (AFDC/TANF) / q Offender / q Deficient in Basic Literacy Skills
q General Assistance / q Alcohol/Drug Dependency / q School Dropout
q Food Stamps / q Homeless / q Requires Additional Assistance to Complete School
q Unemployment Insurance / q Exhausted Welfare Assistance Eligibility / q Skills Grant Barrier (Needs Test)
q Workman’s Compensation Benefits
q Veteran’s Disability Benefits / q Foster Child
q Runaway Youth / q Educational Attainment is one or more grade levels below the grade level appropriate to the age of the individual
q Age 20 or younger and either Pregnant or Supporting one or more Children
Literacy/Numeracy Test Scores: / Test Administered: / Date Administered:
Reading Scale Score: ______/ Math Scale Score: ______
/ Language Scale Score: ______
Reading (EFL) ______/ Math (EFL): ______/ Language(EFL): ______
Youth Education Status: / q Student, High School or Less
q Student, Attending Post High School / q Out-of-School, High School Dropout
q Out-of-School, High School Graduate with Employment Difficulty / q Out-of-School, High School Graduate with NO Employment Difficulty
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Consolidated Application (Certification) Page 2SSN: ______
DISLOCATED WORKER
1. dislocated Worker / q Yes / q No
2. Date of Quality Dislocation
3. Dislocation Hourly Wage
4. Current Hourly Wage
5. Occupation at Dislocation
6. Rapid Response / q Yes / q No
7. Referred by WPRS / q Yes / q No
8. Unemployed/Underemployed homemaker no longer supported by spouse and having difficulty obtaining or upgrading employment / q Yes / q No
9. Trade Adjustment Certified / q Yes / q No
Funding Eligibility
Check the applicable box(es) to indicate all funding streams for which the Applicant is eligible for:
Blue Collar / q / WIA Youth / q / WIA Youth 5% / q / Other / q ______
Valid Driver’s License / License Number ______/ Education
q Yes
q No / A / B / C / D / M / Currently attending school or between school terms but intend on returning to school? / q Yes
q No
State: ______/ Class/Type: / q / q / q / q / q / Number of years of school attend:
Degrees/Diplomas/Certificates/Licenses
Endorsements: / q HAZMAT / q Hazardous/Tank / q Passenger / q Unspecified / q Bachelor’s Degree
q Tank / q Doubles/ Triples / q Less than High School / q Master’s Degree
Access to Public Transportation / q Yes / q No / q High School Diploma / q Doctoral Degree
q Some College / q Professional/Technical/Apprenticeship/Trade Certificate
Current Labor Force Status:
q Employed
q Not Employed
q Never Held a Job / Weeks unemployed during the last 26 weeks:
______
q Associate Degree
q Vocational Degree / q Professional/Technical/Trade License
q Professional/Technical/Trade Registration
Physical or mental disability / q Yes / q No
Does disability constitute or result in a substantial barrier to employment / q Yes / q No / Course of Study
Requires assistance or auxiliary aids to utilize DET services / q Yes / q No / Issuing Institution
Currently receiving Unemployment Insurance benefits? / q Yes
q No / Course Completion Date / _____/______/______
Weekly benefit amount: $______.00 / State: / ______/ County: ______
Recently applied for Unemployment Insurance benefits / q Yes
q No / Certificates/Licenses:
Exhausted a claim for Unemployment Insurance benefits within the last 6 months / q Yes
q No
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Consolidated Application (Certification) Page 3SSN: ______
Migrant Farm Worker/Food Processor
During the last 12 months:
Worked at least 25 days in farm work / q Yes / q No
Veteran Information
Veteran / q Yes / q No
Entitled to Veteran’s preference based on spouse’s military service / q Yes / q No
Vietnam-era Veteran / q Yes / q No
Served during a was, campaign or expedition / q Yes / q No
Recently separated Veteran / q Yes / q No
Service-connected disability / q Yes / q Not
Discharged or released from active duty due to service-connected disability / q Yes / q No
DVA Disability Rating:
q 30% or more
q Less than 30%
q Lessthan 30% with serious employment disability-
q Most recent dates of military service: / From ______/ To ______
Branch of military served:
q Air Force / q Marines
q Army / q Merchant Marines
q Coast Guard / q Navy
Military specialty or occupation
Activity/Goal Enrollment (Initial)
Subcode: ______
Activity Codes
q Educational Achievement Serv. (EAC) [Y] / q Follow Up Services (FUS) [Y] / q Occupational Skills Training (OST)q Employment Services (EMS) [Y]
/ q Intensive Job Search (IJS) / q Summer Employment Opportunities (SEO) [Y]q Job Readiness Training (JRT)
Activity Code
/ Skills Goal Set / Actual Date / Estimated End Date / Estimated # of HoursActivity Code
/ Skills Goal Set / Actual Date / Estimated End Date / Estimated # of HoursActivity Code
/ Skills Goal Set / Actual Date / Estimated End Date / Estimated # of HoursI certify that the information provided is true and the best of my knowledge. I am also aware that the information I have provided is subject to review and verification, and I may have to provide documentation to support this registration. I am also aware that I am subject to immediate termination if I am found ineligible after enrollment and may be prosecuted for fraud and/or perjury if I intentionally supplied inaccurate or misleading information. I allow release of this information for verification purposes and understand that it will be used to determine eligibility. I have been advised of equal opportunity and appeal rights, and the Privacy Act of 1974.
Signature of Applicant / Date
Signature of Parent, Guardian or Responsible Adult (if Applicant is under 18) / Date
Signature of Interviewer / Date
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