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* 1. Are you currently employed?

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* 2. Please specify current hourly wage?

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* 3. If yes to question #1, are you working full-time or part-time?

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* 4. First Name?

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* 5. Last Name?

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* 6. Full Social Security Number?

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* 7. Date of Birth?

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* 8. Personal Email?

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* 9. Phone Number?

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* 10. Alternative Phone Number?

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* 11. Physical Address?

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* 12. County of Residence?

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* 13. Gender?

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* 14. Family size?

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* 15. Number of your dependent children in your household under the age of 18?

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* 16. Are you a US Veteran?

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* 17. Character of discharge from Military service?

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* 18. Disabled Veteran?

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* 19. Are you the spouse or dependent of a veteran?

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* 20. Are you a US Citizen?

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* 21. If you answered no to (question # regarding Citizenship) what is your current status?

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* 22. Have you ever been arrested or convicted of a crime?

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* 23. Highest Education Level Completed?

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* 24. List degrees/licenses/certifications that you’ve earned. Specify the year that you received each.

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* 25. Do you currently receive (or are a member of a *WIOA Defined Family that receives) Food stamps or received Food stamps during the previous six months?

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* 26. What is your annualized family income?

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* 27. Do you or a family member currently receive Temporary Assistance for Needy Families (TANF)?

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* 28. Do you or a family member currently receive Supplemental Security Income (SSI)?

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* 29. Do you currently reside in a homeless shelter?

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* 30. Do you have a disability?

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* 31. Have you been terminated/laid off, are eligible for/exhausted unemployment compensation and are unlikely to return to your previous industry/occupation?

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* 32. Have you been terminated/laid off, or have received a notice of termination/lay off, and have been employed for a minimum of 6 weeks, but are not eligible for unemployment compensation due to insufficient earnings, and are unlikely to return to your previous industry or occupation?

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* 33. Have you been terminated/laid off or have received a notice of termination/layoff from employment as a result of permanent closure or substantial layoff at a plant/facility/enterprise?

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* 34. Has your employer made a general announcement that the facility will close within 180 days

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* 35. Are you an individual who was previously self-employed (with a business license) but are currently unemployed due to general economic conditions or a natural disaster? *Must be able to provide proof of business licenses and tax returns*

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* 36. Have you been dependent on the income of a family member (*WIOA Defined) while providing unpaid services to your family, but are no longer supported by their income and are unemployed/underemployed and are experiencing difficulty in obtaining/upgrading employment?

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* 37. Are you the dependent spouse of a member of the armed forces on active duty and whose family income is significantly reduced because of a deployment/call or order to active duty/permanent change of station or service-connected death/disability of the service member?

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* 38. Are you the spouse of a current member of the military who was forced to leave your employment to follow your spouse due to change in military assignment?

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* 39. Are you a previous member of the military who was discharged from the armed forces under honorable conditions and who did not retire from the military?

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* 40. Are you registered in www.employflorida.com?

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