·CATHOLICCHARITIES,JACKSONVILLE

WorkforceDevelopmentProgramINTERNALREFERRALFORM-Revised07/05/2016

NOTEOURLOCATION: 40EAdamsStreet,Suite#120,Jacksonville,FL32202(904)900-7943Ext. 1204;(904)900-7990fax;COMPLETEONLYIFSEEKINGEMPLOYMENTPLEASEPRINTCLEARLY

CLIENTNAMEDATEAGE

ADDRESSCOUNTYZIPCODE

EMAILADDRESSPHONENUMBER

TheWorkforceDevelopmentProgramisdesignedtohelpyougaintheskillsneededtofindajob.ParticipationintheprogramisFREE,butisonlyavailabletoqualifyingcandidates.Workforceisa4-monthprogramthatrequires attendanceina1-weekjobreadinessclassandweeklyonlinejobapplicationsessions.Thefirststepistoanswerafewquestionstodeterminewhetheryouqualifyfortheprogram.Ifyouqualify,youwould meetface-to-facewithanemploymentspecialistfortheintakeandassessmentprocess.

1.Areyoucurrentlyunemployed[]orunderemployed?[]

a.Ifunemployed:

1.Whendidyourlastpositionend?------

11. Whatwasyourlastjob?------

111.Howlongdidyouworkatthatjob? ------­

iv.Whatwasthereasonforleaving?------­

b.Ifunderemployed:

i.Whatisyourcurrentposition?___

ii.Howlonghaveyouworkedatthisjob?------­

iii.Whyareyoulookingfordifferentwork?

2.Whatjobskillsdoyouhave?

3.Doyouhaveanycertifications?

4.Areyou18yearsorolder?[]Yes[]No

5.Areyoutheheadofyourhousehold []Yes[]No

6.Howmanyindividualsinyourhousehold(adultsandchildren)__

7.AreyoueligibletoworkintheUnitedStates?[]Yes[]No

8.Areyouabletostayinyourcurrenthousingforthenext6months? []Yes[]No

9.Doyouhaveapolicerecord?[]Yes[]No

a.Ifyes,whatwasthecharge?------

b.Misdemeanororfelony(circle)

c. Whendidthatoccur? ------

(Continue onbackofform)

10.Canyouattenda20-hourtrainingprogram_(Monday-Friday8:30_-12:30onEastAdams

.Street)?Busticketswillbegiventoyouifneeded.[]Yes[]No

11.Canyouattendweeklyjobcoachinguntilyougetajob(upto4months)? []Yes[]No

12.Doyouneedaccommodationsforthejobreadinessclassortowork? []Yes[]No

13.Ifyes,whattypesofaccommodationsareneeded?------

14.DoyoumeetSection8incomelimits?Checkbelowchartwithclient. []Yes[]No

COMMUNITYDEVELOPMENTBLOCKGRANTPROGRAM(REVISEDSECTION8INCOMELIMITS)

EFFECTIVEJune2016

FAMILYSIZE / MODERATE
(80%OFMEDIAN)
1 / $36,350
2 / $41,550
3 / $46,750
4 / $51,900
5 / $56,100
6 / $60,250
7 / $64.400
8 / $68,550

DONOTWRITEBELOWTIDSLINE

TOBECOMPLETEDBYCATHOLICCHARITIESSTAFF:

1.Theclientisunemployedorunderemployed?[]Yes[]No

2.Hasjobskills?[]Yes[]No

3.Hasrecentworkexperience(1-3years)?[]Yes[]No

4.ResidesinBaker,Clay,Duval,NassauorSt.JohnsCounty?[]Yes[]No

5.Is18yearsofageoro1der?[]Yes []No

6.IseligibletoworkintheUS? []Yes []No

7.Isinstablehousing(6months)?[]Yes[]No

8.Canattend20-hourjobreadiness?[]Yes[]No

9.Canattendweeklyjobcoachingupto4months?[]Yes[]No

10.MeetsSection8incomelimits?[]Yes[]No

11.Ismotivatedtoseekemployment?[]Yes[]No[]Yes,thisclientqualifiesfortheprogram.

YouwillreceiveaphonecallfromaWorkforceDevelopmentteammemberforanintakeappointment. Pleasebringwithyou: pictureidentification,proofofresidencesuchasaJEAbillwithcurrentaddress,documentationofincome(foodstamps,disability,TANForunemploymentbenefitsletter). Pleasebringyourresumeifyouhaveone.

[ ]No,theclientdoesnotqualifyfortheprogramdueto:___

CCSTAFFREFERRINGCLIENT(PRINT)PROGRAM EXTENSION

CatholicCharitiesStaff:PleaseplacethisformintheWorkforcemailboxinEAorscanand

.:.

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