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Basic Needs Network Authorization Form

  1. Workforce Solutions is a partner of the Basic Needs Network of West Central Texas. The Basic Needs Network is a collaboration of organizations working together to meet the needs of those in need in West Central Texas. These agencies work together to provide and track resources throughout a 19 county service area.

    All recipients of supportive services from Workforce Solutions of West Central Texas must agree to share their data with the Basic Needs Network. By signing this agreement you are agreeing to share information about you, like where you live and your phone numbers; your family, like who is in your family; and the types of services that you are requesting. The information is only used to track and evaluate services provided by the Basic Needs Network. Please complete the authorization below.

  2. Statement of Declaration

    I have been provided information on the Basic Needs Network of West Central Texas+ and agree to share my data. I understand that data on my family will be collected, maintained and entered into a secure database. The information will be used to track services, for evaluation purposes, and to ensure quality services are being provided.

  3. Authorization

    I authorize my family to participate. Select one:

  4. Declaración

    He sido informado por Basic Needs Network del Oest Central de Tejas+ y estoy de acuerdo en compartir mis datos. Entiendo y acepto que los datos sobre mi familia seran recogidos, conservados, y ingresados en una red de datos seguros. La informacion sera usada para conseguir servicios, con proposito de evaluacion y para asegurar la calidad de los servicios proporcionados.

  5. Autorización

    Yo autorizo a mi familia a participar. Seleccione uno:

  6. 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.

  7. Equal Opportunity Employer/Program

    Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice).

  8. Leave This Blank:

  9. This field is not part of the form submission.