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Brownwood Workforce Center Closing at 3 p.m. on Sept. 28
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Application for Workforce Services
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Applicant Information
This section is complete
This section is incomplete
2.
Employment Information
This section is complete
This section is incomplete
3.
Household & Income Information
This section is complete
This section is incomplete
4.
Disclaimer & Signature
This section is complete
This section is incomplete
5.
Optional Equal Opportunity Survey Form
This section is complete
This section is incomplete
Applicant Information
Last Name
First Name
Middle Initial
Date of Birth
Date of Birth
Street Address
Apartment / Unit Number
City
State
Zip
Primary Phone Number
Alternate Phone Number
Email Address
Preferred Method of Contact
-- Select One --
Email
Phone
Text
Mail
Other
How would you like to be contacted?
How did you hear about us?
Friend/Family
Child Care Services
2-1-1 A Call for Help
Facebook/Social Media
Radio
Television
School Counselor
Workforce Staff
Community Agency
Other
Please give the name of the Workforce staff member:
Please give the name of the organization/agency:
(example: Goodwill, Vocational Rehabilitation, etc.)
Please explain how you heard about us:
Alternate Contacts
Please provide contact information for 2 other individuals who can always contact you. In the case that we cannot reach you, we may contact them in our attempts to contact you.
Name
Relationship
Phone
Name
Relationship
Phone
Are you registered with Selective Service (the Draft)?
This applies only to males born after 1960.
Yes
No
N/A
Selective Service Registration Number
Have you or your spouse ever served in the military?
Yes
No
Who?
I Served
My Spouse Served
What branch did you serve in?
What were your dates of service?
What were your dates of service? Start Date
—
What were your dates of service? End Date
What branch did your spouse serve in?
What were your spouse's dates of service?
What were your spouse's dates of service? Start Date
—
What were your spouse's dates of service? End Date
Has your family recently relocated as the result of military relocation / change of duty station?
Yes
No
In the past 24 months, have you earned more than half your wages or spent more than half of your time working in farm or agricultural related work?
Yes
No
Have you ever been or are you currently in the foster care system?
Yes
No
What is your highest level of education?
Do you have your diploma or GED?
Yes
No
Are you currently in school?
Yes
No
If under 18, last date attended:
If under 18, last date attended:
Do you have any other certifications or credentials?
Yes
No
List Certifications or Credentials
Continue
Employment Information
Were you or are you scheduled to be laid off or terminated from your previous/current employer?
Yes
No
When and from where?
Are you currently receiving Unemployment Insurance?
Yes
No
Are you currently employed?
Yes
No
Where are you employed?
Are you registered in WorkInTexas.com (WIT)?
Yes
No
How long have you been actively looking for work?
What is your job search timeline?
(When would you like to be employed?)
Employment History
Complete the following employment history record starting with the most recent. Include your full work history for the last 10 years. Please complete all information. It is acceptable to use city and state for location.
Additional Pages
Attach additional pages if you have had more than 6 jobs in the last 10 years.
Job 1
Company Name
Location
Dates of Employment
Dates of Employment Start Date
—
Dates of Employment End Date
Job Title
Reason for Leaving
Job Duties
Job 2
Company Name
Location
Dates of Employment
Dates of Employment Start Date
—
Dates of Employment End Date
Job Title
Reason for Leaving
Job Duties
Job 3
Company Name
Location
Dates of Employment
Dates of Employment Start Date
—
Dates of Employment End Date
Job Title
Reason for Leaving
Job Duties
Job 4
Company Name
Location
Dates of Employment
Dates of Employment Start Date
—
Dates of Employment End Date
Job Title
Reason for Leaving
Job Duties
Job 5
Company Name
Location
Dates of Employment
Dates of Employment Start Date
—
Dates of Employment End Date
Job Title
Reason for Leaving
Job Duties
Job 6
Company Name
Location
Dates of Employment
Dates of Employment Start Date
—
Dates of Employment End Date
Job Title
Reason for Leaving
Job Duties
Continue
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Household & Income Information
How many people live in your household?
What is your combined annual household income?
Household Members
Please complete the following information for all members in your household (including yourself).
Self Information
Name
Relationship
Age
Annual Income
Source of Income
Receives Any Type of Public Assistance?
Yes
No
Such as SNAP (food stamps), TANF (cash assistance), SSI (Social Security Income), SSDI (Social Security Disability Insurance), etc.
List all public assistance that apply.
Name
Relationship
Age
Annual Income
Source of Income
Receives Any Type of Public Assistance?
Yes
No
Such as SNAP (food stamps), TANF (cash assistance), SSI (Social Security Income), SSDI (Social Security Disability Insurance), etc.
List all public assistance that apply.
Name
Relationship
Age
Annual Income
Source of Income
Receives Any Type of Public Assistance?
Yes
No
Such as SNAP (food stamps), TANF (cash assistance), SSI (Social Security Income), SSDI (Social Security Disability Insurance), etc.
List all public assistance that apply.
Name
Relationship
Age
Annual Income
Source of Income
Receives Any Type of Public Assistance?
Yes
No
Such as SNAP (food stamps), TANF (cash assistance), SSI (Social Security Income), SSDI (Social Security Disability Insurance), etc.
List all public assistance that apply.
Name
Relationship
Age
Annual Income
Source of Income
Receives Any Type of Public Assistance?
Yes
No
Such as SNAP (food stamps), TANF (cash assistance), SSI (Social Security Income), SSDI (Social Security Disability Insurance), etc.
List all public assistance that apply.
Additional Household Member Information
If there are more than 5 individuals in your household, please upload a document with required information for them.
Are you homeless?
Yes
No
Are you a runaway?
Yes
No
Are you authorized to work in the United States?
Yes
No
If you could work one type of job for the rest of your life, what would it be?
Where do you see yourself in the next 6 months?
Where do you see yourself in the next 5 years?
What type of assistance are you seeking?
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Disclaimer & Signature
Disclaimer & Signature
Please sign and provide the date on which you are submitting this application.
Electronic Signature Agreement
*
By checking the "I agree" box below, you agree and acknowledge that: your application will not be signed in the sense of a traditional paper document, by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, you may still be required to provide a traditional signature at a later date.
I Agree
Signature
*
I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application or interview may result in disqualification for financial aid consideration.
Today's Date
*
Today's Date
Scholarship Applicants
You can submit a saved copy of the Scholarship Application (Financial Aid Addendum) with this form. Please also include a copy of your training program acceptance letter, career interest inventory, and any additional information requested by Workforce Solutions staff with this application.
Scholarship Application (Financial Aid Addendum)
Click to Apply Online
Applicants can complete the web-based Scholarship Application instead of submitting a copy with this form.
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice).
Funding
Public Information
This service is funded in whole or in part with federal funds. More detailed information is located on the Public Information page on the Board’s website.
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Optional Equal Opportunity Survey Form
Optional Equal Opportunity Survey Form
The information requested on this form is optional and is being collected for the primary purpose of reporting to federal and equal opportunity reporting agencies. While we request that you respond to each of the line items in order to complete your full application, you may choose whether or not to disclose information by leaving any questions you do not wish to answer blank.
Disclaimer
Information contained in this survey shall be retained in such a manner as to ensure confidentiality and shall be used only for purposes of record keeping and reporting where appropriate for grant-funded programs or activities. Workforce solutions of west central texas is an equal opportunity employer/program and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or beliefs; or against any beneficiary of, applicant to, or participant in programs financially assisted under Title I of the workforce innovation and opportunity act, on the basis of the individual’s citizenship status or participation in any Workforce Innovation and Opportunity Act (WIOA) Title I-financially assisted program or activity.
Last Name
First Name
Middle Initial
Date of Birth
Date of Birth
Marital Status
-- Select One --
Married
Single
Divorced
Widowed
Domestic Partnership
Gender
-- Select One --
Male
Female
Race
Check all that apply.
White
Black or African American
American Indian or Alaskan Native
Asian
Hawaiian Native or Pacific Islander
Ethnicity: Are you of Hispanic or Latino descent?
Yes
No
Do you have a known disability?
Yes
No
Have you ever been convicted of a misdemeanor or felony?
Yes
No
Which?
Felony
Misdemeanor
What is your primary / preferred language?
Are you currently working with any of our community partners?
Please check all that apply.
Adult Education and Literacy
MET
Vocational Rehabilitation
Other
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that: your application will not be signed in the sense of a traditional paper document, by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, you may still be required to provide a traditional signature at a later date.
I Agree
Signature
I certify that my answers are true and complete to the best of my knowledge.
Date
Date
Leave This Blank:
Submit
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