Adult and Dislocated Worker Programs Application

Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone *

(###)

###

####

Cell Phone *

(###)

###

####

Checkbox *

Do you accept text messages?

Yes

No

Message Phone *

(###)

###

####

Relative's Name *

First Name

Last Name

Relative's Phone *

(###)

###

####

Birthdate *

MM

DD

YYYY

Sex (at birth) *

Male

Female

Are you Hispanic or Latino? *

Yes

No

Prefer not to answer

What is your Race? *

Select one or more:

White or Caucasian

Asian or Asian American

Black or African American

Hawaiian or Other Pacific Islander

American Indian or Alaska Native

More than one race

Prefer not to answer

Do you acknowledge a disability that substantially limits one or more major life activity? *

Yes

No

If yes, do you need special accommodations for the disability?

Yes

No

Do you receive Social Security Disability Insurance? *

Yes

No

Do you have trouble solving problems OR reading, writing, and speaking English at a level necessary to function on the job? *

Yes

No

Is English your primary language? *

Yes

No

Do you live in a family or community where English is not the primary language spoken? *

Yes

No

Are you registered with Selective Service? *

Yes

No

Are you a U.S. Citizen? *

Yes

No

If no, are you a permanent resident alien?

Yes

No

If no for both above, are you a lawfully admitted refugee, asylees, parolee, or other immigrant authorized to work in the United States?

Yes

No

N/A

Are you a veteran? *

Yes

No

Have you registered with Arkansas Job Link? *

Yes

No

Are you an Arkansas Works referral from the state Medicaid expansion program? *

(Arkansas Works is a Governor's initiative DHS program that refers DHS clients to DWS job service staff for employment assistance)

Yes

No

Have you been subject to any stage of the criminal justice process for committing an offense or delinquent act, OR do you have trouble obtaining or keeping a job because of an arrest or conviction? *

Yes

No

Are you a single parent (custodial or non-custodial), or a pregnant woman? *

Yes

No

Do your customs, beliefs, or practices serve as a hindrance to employment (cultural barrier)? *

Yes

No

Do you or a family member currently receive (or received in the last 6 months) any of the following?

Check all that apply:

SNAP

TEA

Work Pays

Supplemental Security Income (SSI)

Are you within 2 years of exhausting your lifetime TANF eligibility? *

Yes

No

Are you homeless (lack a fixed, regular, and adequate nighttime residence)? *

Yes

No

Do you certify that all the income sources above are all the sources of income for your family? *

Yes

No

Which best describes your current employment status? *

Check all that apply:

Employed working for wages, self-employed, or working 15+ hours per week unpaid in family business. ("Employed" includes if you are away from job because of vacation, leave, etc.)

Part-time (PT is less than 30 hrs/wk or considered PT by your employer)

Full-time

Self-Employed

Employed, but received termination notice from employer/military

Not employed (not working, but available for work and looking for work)

Exhausted Unemployment Benefits, and don't have an appropriate job

Have been unemployed for 27 or more consecutive weeks, but have been looking for work and was available for work during the entire time

Not in labor force (not employed and have not actively been looking for work)

Are you a migrant or seasonal farm worker? *

Yes

No

Do you currently receive Unemployment Benefits? *

Yes

No

Have you received Unemployment Benefits in the past? *

Yes

No

Have you recently been laid off or given notice that you will be laid off? *

Yes

No

Layoff date

MM

DD

YYYY

Did you own a business that recently closed because of a disaster or local economic reasons?

Yes

No

Closure date

MM

DD

YYYY

Are you a displaced homemaker (a person who has been providing unpaid services to family members in the home and has been dependent on the income of a family member, but is no longer supported by that income and is unemployed or underemployed and is experiencing difficulty obtaining or upgrading employment)?

Yes

No

Are you (or were you) the dependent spouse of a member of armed forces on active duty, and the family income is significantly changed because of a deployment, a call or order to active duty, a permanent change of state, or the service-connected death or disability of the member?

Yes

No

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Do you have a high school diploma or GED? *

Yes

No

Do you have a college degree or certificate? *

Yes

No

Do you have college work toward an unfinished certificate? *

Yes

No

Are you currently enrolled in postsecondary education (college, technical school, etc.)? *

Yes

No