Eligible Training Provider Application - West Central Arkansas Planning & Development District

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West Central Arkansas Planning & Development District

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WIOA Qualification Questionnaire

- Step 1 of 4

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County of Residence *

Other *

Phone *

Email *

What is your age range? *

16-17
18-21
22-24
25-54
55-59
60-100

How much school have you completed? *

Less than High School Diploma
High School Diploma or equivalent
Some College/Training
Enrolled in College
Associates Degree or Higher

Which of the following best describes your current employment situation? *

Employed
Unemployed
Will be laid off or let go soon
Farmworker looking for work
Student

Have you served in the military? *

Not a Veteran
Veteran/Served in the military
Transitioning Service Member
Spouse of a Veteran

of the kind

What is your monthly income? *

How many people do you support (including yourself)? *

What kind of support do you need the most? *

I want to grow my income.
I want more education.
I want to build my skills.
I want to change my career.

Challenges- Tell us more about your current situation. *

I don't have the right skills to get the job I want.
I don't have the right education.
Technology is confusing.
I don't have reliable transportation.
I have a disability
I don't speak English
I don't have childcare
History with the Justice System
I'm homeless
I'm in Foster Care

Under The Applicable Provisions Of The Privacy Act Of 1974, I hereby certify, that I have not withheld any information that could affect the services that I may qualify for through West Central Arkansas Workforce Development Area (WCAWDA) and that, to the best of my knowledge, all the above information is true and correct. I understand any willful misstatement of facts may cause forfeiture of program eligibility. I understand that the above information is subject to verification, and will be handled by WCAWDA staff as "Confidential", and may be shared with other partners and/or federal, state, and/or local government/non-government agencies/organizations on a strict "need to know" basis. I agree to provide additional documentation that may be required to assess my needs relevant to WCAWDA/partner program services. By clicking the submit button, you agree to receive communications from the West Central Arkansas Workforce Development Area, including partners, via phone, mail, and email.

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