BEFORE YOU START ASKING US IF WE GOT YOUR APPLICATION: After you click the 'Submit' button at the bottom of this page, you will see "Thank you for your worksheet. It has been sent and will be processed." inside a green box, if your form made it to our database. If you see the green box, we received your application and will be processing it. Take a screen shot of your green box if you feel the need. If you got a red box instead, that means you're missing some information in one or more of the boxes. Scroll back up and fill in the empty boxes. Then click 'Submit' button at the bottom of the page again, and look for the green box. ____________________________________________________________ 1. CONTACT INFORMATION First Name Middle Name Last Name Date of Birth Social Security # Program Start Date Email Address Address Apartment # City State Zip Code Cell Phone Work Phone ____________________________________________________________ 2. GENDER MaleFemaleX 'X' includes Trans, Non-Binary, Two-Spirit, and Binary people and people who don't want to disclose their gender identity ____________________________________________________________ 3. RACE/ETHNIC IDENTITY Native American or Alaskan NativeAfrican American/African/Afro-CaribbeanLatino or HispanicWhite (not Latino/a)Other If Other, please describe Country of Birth Date of US Settlement Native Language Immigrant? YesNo Refugee? YesNo ____________________________________________________________ 4. Employment Status Employed Full-TimeEmployed Part-TimeUnemployedNot available for employmentSelf-employedReceived a 1099 Form for work If unemployed, how long Years: Months: Employer's Name Job Title Hourly Rate of Pay Average hours worked weekly Work Location ____________________________________________________________ 5. MARITAL STATUS SingleMarriedWidowedSeparatedDivorced Number of Adults in Household Number of Children (under 18 y.o.) in Household Average Household Income 0 – $14,999$15,000 – $24,999$25,000 – $34,999$35,000 – $44,999$45,000 – $54,999$55,000 – $64,999$65,000 – $74,999> $75,000 Are you a Veteran? YesNo ____________________________________________________________ 6. PUBLIC ASSISTANCE Not received Public AssistanceSNAP (EBT card)MEDICAIDSection 8 AssistanceOld-aged AssistanceSupplemental Security Income (SSI)Social Security Disability (SSD)Safety NetAid to the Blind or Totally DisabledOther If Other, please specify Case Number Are you collecting Unemployment Insurance Benefit? YesNo ____________________________________________________________ 7. EDUCATIONAL BACKGROUND Less than 12 GradeHigh School DiplomaPost Secondary EducationOther If Other, please specify Credential (Certifications and Licenses) achieved in the US: ____________________________________________________________ 8. UNION AFFILIATION Are you a Union Member or Family of a Union Member? YesNo If Yes, are you a MemberFamily of a Member Union Affiliation Local Number ____________________________________________________________ 9. School Aged Children Are you the parent or guardian of children under the age of 21? YesNo If yes, are you a single parent? YesNo If yes, enter number of children at each level Pre-school Elementary Junior High School High School Post-Secondary ____________________________________________________________ 10. POPULATION CATEGORIES HomelessIn Correctional FacilityOther InstitutionalizedHigh School Graduate or EquivalentDisplaced HomemakersHead of HouseholdDisabledEnrolled in Other Education/TrainingVeteransDislocated WorkersEmployed at 200% of Poverty LevelLow IncomeNYCHA ResidentLearning DisabledNon Native English SpeakerOther If Other, please describe ____________________________________________________________ 11. REFERRAL SOURCE Workers UnionOther If Other, please describe ____________________________________________________________ 12. WORKER GOALS Obtain a JobRetain Current JobImprove Current JobEnter TrainingEnter an Apprenticeship ProgramEarn High School DiplomaEnter Post-Secondary EducationImprove Basic Literacy SkillsImprove English Literacy SkillsOther If Other, please describe Δ