Pre-Intake WIOA Application Start your application here "*" indicates required fields 1Welcome2About You3Contact4Education5Employment6Work History7WIOA Eligibility8Ethnicity & Language9Military & Emergency10Self-Disclosure11Income12Notices13Review14Certification FacebookThis field is for validation purposes and should be left unchanged.WelcomeWelcome!This application helps us connect you with job search services, training, and employment support through the South Valley WorkSource Center.It takes about 15-20 minutes to complete, and you can save your progress at any time and come back later.Let’s get started!Pre-Intake Consent* I understand this online form is a pre-intake application and final eligibility will be determined later by staff. Applicant IdentityFirst Name*Middle InitialLast Name*Date of Birth* Month Day Year AgeGender Female Male Other CitizenshipWhat is your citizenship status?* US Citizen Permanent Resident Alien/Refugee Lawfully Admitted to US None of the Above Selective ServiceHave you registered with the Selective Service? Yes No Not Applicable AddressResidential Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address the same as above?* Yes No Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact InformationPrimary Phone*Primary Phone Type— Please Select —Cell/MobileRelativesWorkNot IdentifiedHomeOtherAlternate PhoneAlternate Phone Type— Please Select —Cell/MobileRelativesWorkNot IdentifiedHomeOtherEmail Address* Contact PreferencesWhat is your preferred method of contact? Phone Call Email Text Message May we send you a text message if necessary? Yes No Education BackgroundDid you obtain your High School Diploma or GED? Diploma GED No If no, what is the highest grade level you completed?Do you have any college or technical/vocational education? Yes No How many years or what type of degree? Less than HS 12 – High School/GED 14 – AA/AS Degree 16 – Bachelor Degree 18 – Master’s Degree 20 – PhD / Doctorate Are you currently attending school? Yes, Attending HS/JR HS/Middle/Elementary Yes, Attending College or Technical or Voc School Yes, Attending An Alternate School No, Not Attending Any School Current EmploymentWhat is your current employment status? Working Full Time Working Part Time Not Working Never Worked Employed With Notice of Termination/Military Separation Other What type of business have you worked in?— Please Select —Private BusinessLocal GovernmentFederal GovernmentHigher EducationState GovernmentEducation (K-12)Non ProfitHave Never WorkedOtherAre you currently looking for work? Yes No Desired JobWhat is your desired job title?List all positions you are seeking. Do NOT put Open or Any.Layoff / SeparationWithin the last 12 months, have you received a notice of termination or layoff from your job or received documentation that you are separating from military service? Yes No What type of notice did you receive? Layoff/Termination Military Separation Both Date of Layoff/Termination Month Day Year Date of Military Separation Month Day Year Farm WorkerHave you worked on a farm or as a migrant/migrant food processor at least 25 days in the past 12 months? Yes No Work HistoryDo you have any work history? Yes No Work History 1 (Most Recent Job)Are you still employed at this job? Yes No Begin Date Month Day Year Last Day Worked Month Day Year Job TitleEmployer NameEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer PhoneHourly WageHours Worked Per WeekJob DutiesType of Employment Regular Temporary Seasonal Contract Volunteer Full time or part time? Full Time Part Time Reason for Separation Still Employed Better Job Opportunity Job Ended Labor Dispute/Strike Layoff Leave of Absence Part Time or Reduced Hours Resigned/Quit Retired Terminated/Fired Other If other, please explainWork History 2Would you like to add another job? Yes No Are you still employed at this job? Yes No Begin Date Month Day Year Last Day Worked Month Day Year Job TitleEmployer NameEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer PhoneHourly WageHours Worked Per WeekJob DutiesType of Employment Regular Temporary Seasonal Contract Volunteer Full time or part time? Full Time Part Time Reason for Separation Still Employed Better Job Opportunity Job Ended Labor Dispute/Strike Layoff Leave of Absence Part Time or Reduced Hours Resigned/Quit Retired Terminated/Fired Other If other, please explainWork History 3Would you like to add another job? Yes No Are you still employed at this job? Yes No Begin Date Month Day Year Last Day Worked Month Day Year Job TitleEmployer NameEmployer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer PhoneHourly WageHours Worked Per WeekJob DutiesType of Employment Regular Temporary Seasonal Contract Volunteer Full time or part time? Full Time Part Time Reason for Separation Still Employed Part Time or Reduced Hours Better Job Opportunity Job Ended Labor Dispute/Strike Layoff Leave of Absence Resigned/Quit Retired Terminated/Fired Other If other, please explain WIOA Employment EligibilityWhat is the projected date of your layoff? Month Day Year Did you attend a group orientation (Rapid Response)? Yes No What was the most recent date you attended Rapid Response? Month Day Year What is your Unemployment Insurance compensation status? Eligible Claimant Referred By WPR Not Referred By WPRS Exhaustee Not Applicable Neither Claimant Or Exhaustee This refers to your current status with the Employment Development Department (EDD). If you are unsure, select Not Applicable.Individual BarriersAre you a displaced homemaker? Yes No A displaced homemaker is someone who has primarily provided unpaid household services for their family and is now unemployed or underemployed due to the loss of spousal support, and needs assistance to re-enter the workforce.Do you speak limited English? Yes No Are you a single parent? Yes No Are you homeless? Yes No Public AssistanceAre you receiving Family CalFresh (Food Stamps)? Yes No Are you receiving Family CalWorks (Cash Aid)? Yes No Are you receiving Family Refugee Cash Assistance? Yes No Are you receiving Single CalFresh (Food Stamps)? Yes No Are you receiving Single GR (Cash Aid)? Yes No Are you receiving Single Refugee Cash Assistance? Yes No Are you receiving a Pell Grant? Yes No Ethnicity and RaceAre you of Hispanic or Latino heritage? Yes No I do not wish to answer What is your race? African American/Black American Indian/Alaskan Native Asian Hawaiian/Other Pacific Islander White I do not wish to answer Asian Subcategories Indian Bangladeshi Nepalese Bhutanese Chinese Malaysian Laotian Vietnamese Pakistani Sri Lankan Sikkimese Japanese Korean Thai Cambodian Filipino Other Asian Pacific Islander subcategories: Samoan Palauan Guamanian Micronesian Marshallese Other Pacific Islander LanguageWhat is your primary language? English Spanish Other If other, what is your primary language?What is your native language? English Spanish Other If other, what is your native language?What is your preferred language? English Spanish Other If other, what is your preferred language? Military ServiceAre you currently in the military, a veteran, or the spouse of a veteran? Yes No Are you the spouse/dependent of someone in active-duty military, National Guard or Reserves who is currently activated? Yes No Are you within 24 months of retirement or 12 months of discharge (Transitioning Service Member)? Yes No Have you served on active duty and were discharged other than dishonorable? Yes No Are you the spouse of a veteran with a total service-connected disability, MIA, POW, or who died from a service-connected disability? Yes No Have you served in a National Guard or Reserve unit called to active duty (Title 10 Activation)? Yes, I am serving Yes, I have served No, I am not serving Veteran DetailIndividual Is A Transitioning Service Member Yes No What type of transitioning service member are you? Within 24 Months of Retirement Within 12 Months of Discharge Not Applicable What is your estimated discharge date? Month Day Year Have you served in the US Military, Naval or Air Service? Yes, <= 180 Days Yes, Eligible Veteran Yes, Other Eligible Person No Did you serve more than 1 tour of duty? Yes No Military Service Begin Date Month Day Year Military Service End Date Month Day Year Are you a campaign veteran? Yes No Are you a recently separated veteran (within last 48 months)? Yes No Have you attended a TAP workshop within the last 3 years? Yes No Emergency ContactEmergency Contact NameEmergency Contact Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact PhoneEmergency Contact Email Emergency Contact Relationship Self-DisclosureIn our efforts to improve our training and job placement services, we are asking customers to answer a few additional questions related to employment. All data provided on this form is Confidential. The information you provide will be kept private, and will not be disclosed to anyone, except as otherwise required by law.Disability and BenefitsDo you have a disability? Yes, I have a disability No, I do not have a disability Not specified Are you currently receiving Disability Insurance? Yes No Don’t know Are you a disabled veteran? Yes, I am a disabled veteran Yes, special disabled (Over 30%) No Are you currently receiving SSDI? Yes No Don’t know Social Security Disability Insurance (SSDI) is a federal benefit for people who have worked and paid Social Security taxes but can no longer work due to a disability.Are you currently receiving SSI? Yes No Don’t know Supplemental Security Income (SSI) is a federal benefit for people with limited income and resources who are aged, blind, or disabled.Are you currently receiving Family Social Security Insurance? Yes No Don’t know Do you have a work restriction? Yes No, I do not have a restriction Not specified A work restriction is a limitation on the type or amount of work you can do, such as not being able to stand for long periods or lift heavy objects.Are you currently a Ticket to Work participant? Yes No Don’t know Ticket to Work is a free Social Security program that helps people with disabilities move toward financial independence through employment.Individual BarriersHave you ever been convicted of a criminal offense? Yes No This information is confidential and helps us connect you with appropriate services.Parolee NumberDo you have a history of substance use challenges? Yes No This information is confidential and helps us connect you with appropriate services.Are you currently or have you been involved in gang activity? Yes, currently involved Yes, previously involved At risk of involvement No This information is confidential and helps us connect you with appropriate services and safety planning.Which of the following make it hard for you to get a job? Limited education or training Limited work history/experience No child care Substance use Limited transportation Language barrier Ex-Offender Housing/homeless Disability Background Clearance Issues Income InformationWhat is your current or most recent hourly wage?Auto-populated from work history if available. You may edit this value.Family CompositionYour IncomeYour Gross Income (Past 6 Months)Do you have a spouse (legally married)? Yes No Spouse NameSpouse Gross Income (Past 6 Months)How many dependent children under 18 live in your household?— Select —012345Dependent Child 1Child 1 NameChild 1 AgeChild 1 Gross Income (Past 6 Months)Enter 0 if no income.Dependent Child 2Child 2 NameChild 2 AgeChild 2 Gross Income (Past 6 Months)Enter 0 if no income.Dependent Child 3Child 3 NameChild 3 AgeChild 3 Gross Income (Past 6 Months)Enter 0 if no income.Dependent Child 4Child 4 NameChild 4 AgeChild 4 Gross Income (Past 6 Months)Enter 0 if no income.Dependent Child 5Child 5 NameChild 5 AgeChild 5 Gross Income (Past 6 Months)Enter 0 if no income.Calculated TotalsTotal Household 6-Month Gross IncomeAuto-calculated from all household members.Annualized Family IncomeAuto-calculated: Total 6-Month Income x 2.Family SizeAuto-calculated: 1 (you) + spouse + dependent children.AcknowledgementI acknowledge that I am disclosing accurate personal information* I acknowledge that I am disclosing accurate personal information from the best of my knowledge. Acknowledgement SignatureAcknowledgement Date Month Day Year Complaint Resolution and Equal Opportunity NoticesPlease review the Complaint Resolution Procedures and Equal Opportunity Notice before signing below.View Notices (PDF)I have reviewed and understand the notices I have reviewed and understand the Complaint Resolution Procedures and Equal Opportunity Notices. SignatureDate Month Day Year Were the notices provided in another language? Yes No If yes, what language?Were the notices accessed in an alternate format? Yes No If yes, what format? Review Your ApplicationPlease Review Your AnswersUse the step navigation at the top to go back to any section and make changes.Loading your application summary…Print / Save as PDFEmail My Summary Before You SubmitHow did you hear about us?— Please Select —CalJOBSCommunity Organization / Partner AgencyEDD / Unemployment OfficeFlyer or PosterFriend or Family MemberGoogle SearchGovernment Agency Referral (DPSS, Probation, etc.)Job Fair or Community EventReferred by a Current or Former ParticipantSchool or Training ProviderSocial Media (Facebook, Instagram, etc.)Walk-InWorkSource Center WebsiteOtherIf other, please specifyIs there anything else you would like us to know?Share any goals, resources you need, or questions to help your case manager prepare for your appointment.Final CertificationApplicant Certification Statement: I certify that the information on this application is accurate to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of rights in the WIOA Program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for WIOA. I further understand and agree that my social security number and other information on this application will be provided to other government agencies if required by law.I have read and agree to the above certification statement* I have read and agree to the above Applicant Certification Statement. Applicant Signature*Applicant Signature Date* Month Day Year