COLORADOEMPLOYMENTFIRSTENROLLMENTFORM – HYBRID (Mandatory/Voluntary)

Today’sDate: / FATech: / Office: / ESL: Yes No
Participantis:UnderSanctionExpedited/ComplyABAWD Non-ABAWDVolunteer
Name: / DOB:
Address: / CBMSCase#:1B
City/State/Zip:CO / SSN:
Phone Number: / Email Address:
CurrentlyWorking Yes/No / DateLastWorked: / HighestGradeCompleted:

You arescheduled forOrientationwith theEmploymentFirst(EF)Program on:

Date: ______, at ______() Allow at least hours for orientation.

Case Manager
Location Contact Info. / Address:
City/State/Zip:
EF Phone #: / EF Fax #:
EF Email:

- If you are receiving food stamps and are between ages 18-49, with no children in the home under the age of 18 and do not qualify for any federal exemptions, you must meet a monthly work requirement to keep your food assistance benefits for longer than three months in any 36 month period. You can learn more by attending your orientation.

I also understand that I am required to attend all scheduled meetings, including my orientation meeting as specified above as I am in a Mandatory Employment First County. At orientation I will receive further information on my participation requirements and options. You are amandatoryparticipant in the EF programandare requiredto keepallscheduledappointmentsin order to be eligible for food assistance.Failureto dosowithout verifiablegoodcausewillresultin theimmediatenotice ofnon-participation to theFood AssistanceOffice.As a resultyou could loseyour food assistancebenefitsfor up to6 months inall Coloradocounties.

Ialso understandthatIamNOTrequiredto attendany scheduledmeetings,includingmyorientationmeetingasspecifiedabove as I am in a Voluntary Employment First County. If I choose to attendorientation,Iwillreceivefurtherinformationabout resources, services, andsupports.MyongoingparticipationisNOTrequiredinordertobeeligiblefor foodassistancebut it is encouraged.

Employer: / ContactName:
Phone#:
Position: / StartDate: / HourlyWage: / Hours/Week: / Pay frequency:
EmploymentType(Circle): / Permanent(over90days) / Temporary(30-90days) / Temporary(under30days)
Employer Signature:

Iunderstandthatbysigningbelow,Iauthorizeanyperson,agency,oremployertosupplyinformationaboutmyemploymentorprogramparticipationtotheEmploymentFirstProgram.IfIamanotherhouseholdmembersigningfortheparticipant,Iagreetoinform thepersonbeingreferredoftheirappointmentdate,timeandlocations listed above and understandthatfailuretoreportmayresultinthereductionorlossoffoodassistancebenefitsformyhousehold.

ClientSignature: / PhoneNumber:

F-102(R9/2017)Original–EmploymentFirst Yellow – FoodAssistanceCaseFilePink– Participant 615-82-22-1117