Workforce Development Board (WDB) Application

Workforce Development Board Application

Application Date

Do you need help getting a job or do you need help with training and training-related expenses?

I want help getting a job and do not wish to enroll in training now. (Complete Section I only.)

I need help with training and training-related expenses. (Complete All Sections)

Are you eligible to work in the United States?

Yes

No (If no, contact staff before completing)

What is your Career Goal?

How did you hear about us?

Section I: Demographic Information

Name

Address (including City, State, ZIP)

Home Phone

Cell Phone

Secondary Email

Date of Birth

Highest Educational Level Completed

Last School Attended

Date Last Attended

List any certifications or degrees your currently hold

Do you have dependent children?

Yes

If yes, how many?

Do you have access to a computer and the Internet?

Yes

Are you (or were you previously) in Foster Care?

Yes

Upon completion of training, do you intend to seek full-time paid employment in the occupation in which you were trained?

Yes

Upon completion of training, where do you intend to seek employment?

Are you a Veteran?

Yes

Are you a spouse of a Veteran?

Yes

Branch of Service

Final Rank

Discharge Date

Type of Discharge

Special Training Received

If you are unemployed, list number of weeks unemployed in the past 26 weeks.

Unemployment Insurance Benefits (Check all that apply)

Applied

Received

Exhausted

Available Work Hours

Section II: Assistance Needed to Obtain Career Goal

Funding is available for all or most of these situations. Your answers help us see what programs you may be eligible for. All information is confidential and held in the strictest of confidence.

Check all of the following that apply to you:

In a low-wage job

Disability

Homeless

Childcare issues

Transportation issues

Struggles with Reading/Writing/Math

Struggles with Technology

English is not my primary language

Substance Use (alcohol, street drugs, prescription drugs)

Criminal History: Charges

State

List any Pending Charges

State

If you have additional barriers, please include in Section VI.

Section III: Employment and Experience

Have you worked during the last six months?

Yes

If yes, what is the total gross amount you earned?

Have you ever been fired or forced to resign from a job?

Yes

Text If yes, please explain

List your employment experience (most recent first)

Company

Phone

City

State

Job Title

Wage

Date Employment Begin

Date Employment Ended

Hours Worked per Week

Job Duties

Reason for Leaving

If you have additional work experience, please include in Section VI.

Section IV: Household Information

List family members living in your home and any wage and benefit amount they’ve received in the past six months:

Your Information:

Wages: $

TANF: $

SNAP: $

UI: $

SSI: $

SSDI: $

Survivors: $

Retirement: $

Child Support: $

Veteran's Assistance: $

Other income: $

Child Support: $

Veteran's Assistance: $

Other income: $

Family Member's Information:

Wages: $

TANF: $

SNAP: $

UI: $

SSI: $

SSDI: $

Survivors: $

Retirement: $

Child Support: $

Veteran's Assistance: $

Other income: $

If you have additional family members in your home, please include in Section VI.

Section V: Household Information

List family members living in your home and any wage and benefit amount they’ve received in the past six months:

The New River/Mount Rogers Workforce Development Board programs provide financial assistance for individuals who want to improve themselves through training and employment. Please tell us a little about yourself, your career goals, and how these programs can help support you in successfully accomplishing your goals. Use this opportunity to provide as much detail about yourself.

Certification

I certify the following: I certify that the information provided is true to 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 documents to support this application. 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. I allow release of this information for verification purposes and understand that it will be used to determine eligibility. I further certify that, to the best of my knowledge, no member of my immediate family is employed in any administrative or supportive function in the New River/Mount Rogers Workforce Development Board or any agency or supported by the board. As used here, “family” means “two or more persons related by blood, marriage, or decree of court, who are living in a single residence and are: (1) a husband, wife, and dependent children, or (2) a parent or guardian and dependent children, or (3) a husband and wife.”

Applicant's E-Signature

Date

Parent's E-Signature if under 18

Date

Section IV: Household Information

Applicant and/or Staff: Include any information about this applicant not otherwise on this form that can help determine the applicant’s eligibility and suitability for program funding.

Section I: Demographic Information

Section II: Assistance Needed to Obtain Career Goal

Section III: Employment and Experience

Section IV: Household Information

Your Information:

Family Member's Information:

Section V: Household Information

Section IV: Household Information

Jumpstart your career with NR/MR Workforce Development!