WIOA Qualification Questionnaire - West Central Arkansas Planning and Development District Inc.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

How much school have you completed? *

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

Have you served in the military? *

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

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.

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.