Application

Last four of Social Security Number *

How Did You Hear About Us? *

AARP Foundation Adult Education Arkansas Rehabilitation Services Dept of Human Services - SNAP/TANF/TEA Division of Workforce Services Division of Services for the Blind Facebook Flyer about WIOA Services Goodwill Industries of Arkansas Job Corps Mirgrant Seasonal Farm Workers Senior Community Serv Emp Program Walk In - Didn't Hear about before Other - Please explain in Comment Section at the bottom of the page

Phone Number including area code *

2nd Phone Number including area code *

Sex (at birth) *

Male Female

Ethnic Hispanic/Latino *

Yes No Do Not Self Identify

Race (check all that apply) *

Current Job Status *

Employed Unemployed

Are you a Veteran? *

Yes No

Are you a spouse of a Veteran? *

Yes No

Have you obtained your high school diploma or GED? *

Yes No

Have you received food stamps (SNAP) in the past 6 months? *

Yes No

Have you received Transitional Employment Assistance (TEA) in the past 6 months? *

Yes No

Have you received supplemental security income (SSI) in the past 6 months? *

Yes No

Are you currently receiving Social Security Disability Income (SSDI)? *

Yes No

Are you currently receiving or have exhausted unemployment insurance (UI) benefits? *

Yes No

Have you been laid off or received a notice of layoff from your employer? *

Yes No

Have you been unemployed for 27 or more consecutive weeks? *

Yes No

ARE YOU A SINGLE PARENT (MINOR CHILD WHO IS 17 YEARS OR YOUNGER)? *

yes No

Are you a pregnant single woman? *

Yes No

ARE YOU 24 OR YOUNGER AND PREGNANT OR PARENTING? *

Yes No

Displaced Homemaker - Do any of the following situations apply to you? *

Has been dependent on the income of another family member but is no longer supported by that income. Have you been divorced or legally separated from your spouse in the past 4 years? Have you received alimony in the past 6 months? Have you received child support in the last 6 months? Were you supported by a spouse that passed away in the past 4 years? Have you been dependent on the income of someone who has been terminated or laid off? Does not apply

Disability - Do any of the following situations apply to you? *

Physical Disability? Mental Disability? Learning Disability? Does not apply

Homeless - Do any of the following situations apply to you? *

You are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason. You are living in a motel, hotel, trailer park or campground due to the lack of alternative adequate accommodations. You are living in an emergency or transitional shelter. You are abandoned in a hospital or are waiting foster care placement. Your primary nighttime residence is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, such as a car, park, abandoned building, bus or train station, airport or camping ground. You are a migratory child who in the preceding 36 months, was required to move from one school district to another due to changes in the parent’s or parent’s spouse’s seasonal employment in agriculture, dairy, or fishing work. You are under 18 years of age and absents himself or herself from home or place of legal residence without the permission of his or her family (i.e. runaway youth.) Are you sleeping on a friend's couch? Does not apply

Basic Skills Deficient - Do any of the following items apply to you? *

Are you unable to speak English well enough to conduct a normal conversation with or follow the instructions of an English-Speaker? Are you unable to read English well enough to follow written instructions, including a manual or a recipe? Are you unable to read and write well enough to complete an application for services or an application for employment? Are you unable to pass a driver’s license test written in English? Are you unable to make change or determine if correct change was given back at a store/restaurant? Are you unable to obtain a job at above minimum wage? Must also document by employment history. Are you a high school dropout with no education past the eighth grade? Does not apply

HAVE YOU WORKED ON A FARM DURING THE PAST TWO YEARS? *

Yes No

Are you 55 years or older? *

Yes No

HAVE YOU EVER BEEN SUBJECT TO ANY STAGE OF THE CRIMINAL JUSTICE PROCESS (JUVENILE AND/OR ADULT) FOR COMMITTING A STATUS OFFENSE OR DELINQUENT ACT? *

Yes No

ARE YOU IN OR HAVE YOU AGED OUT OF THE FOSTER CARE SYSTEM? *

Yes No

IS ENGLISH YOUR PRIMARY LANGUAGE? *

Yes No

Are you in default of student Loan? *

Yes No

Current GPA *

3,0 to 4.0 2.0 to 2.9 1.9 or below

What college are you attending? *

What is your expected graduation date? *

What is your major? *

Have you applied for Pell/Fafsa? *

Yes No

List Other Funding *

WIOA Services - Initial Application