Region One - Workforce Development Training Assistance Pre-screening

Eligibility Pre-screening

Many individuals that are seeking employment or training in a high demand occupation may qualify as eligible for assistance from the local Workforce Development Boards, Business and Career Solutions Centers, and the Louisiana Workforce Commission. Your answers to these questions will help us determine if you meet initial criteria for certain funding assistance, that may include, tuition, supplies, tools, fees, stipends, paid On-the-job Training, etc. Please complete all questions with accurate information so that we may assess your situation and provide the most assistance. If you are likely to be eligible based on your answers, you will be contacted to provide additional documentation to verify your eligibility.

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* 1. Please provide the following contact information

First Name *

Last Name *

Parish you where you currently live: *

Primary Phone Number: *

Alternate Phone Number:

Email Address that is checked often: *

Phone Number that is available to receive Text Message:

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* 2. Which of our Training Provider partners referred you for eligibility determination? Select One

Delgado Community College

South Central Louisiana Technical College, River Parishes Campus

Fletcher Technical Community College

Northshore Technical Community College

Nunez Community College

Other (please specify below)

Please name Other

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* 3. What is the name of the training or certificate program.

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* 4. What is your current employment situation?

I am not currently working

I am currently working full-time (more than 30 hrs a week)

I am currently working part-time

Other (please specify)

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* 5. Please answer the following questions to assist us in determining your eligibility as a "dislocated worker" Please answer each question carefully and accurately.

	Yes	No
Are you a recently separated veteran?	Are you a recently separated veteran? Yes	Are you a recently separated veteran? No
Are you the surviving spouse of a veteran who is eligible for VA benefits?	Are you the surviving spouse of a veteran who is eligible for VA benefits? Yes	Are you the surviving spouse of a veteran who is eligible for VA benefits? No
Are you receiving or have you exhausted unemployment benefits?	Are you receiving or have you exhausted unemployment benefits? Yes	Are you receiving or have you exhausted unemployment benefits? No
Were you laid off in the last 7 years and now making less wages than before?	Were you laid off in the last 7 years and now making less wages than before? Yes	Were you laid off in the last 7 years and now making less wages than before? No
Did your previous employer close or go out of business?	Did your previous employer close or go out of business? Yes	Did your previous employer close or go out of business? No
Did you work less than 20 hours a week in your last job?	Did you work less than 20 hours a week in your last job? Yes	Did you work less than 20 hours a week in your last job? No
Was your last employer a temporary employment agency?	Was your last employer a temporary employment agency? Yes	Was your last employer a temporary employment agency? No
Are you not likely to return to your previous occupation with the skills you currently have?	Are you not likely to return to your previous occupation with the skills you currently have? Yes	Are you not likely to return to your previous occupation with the skills you currently have? No
Were you self-employed, but the economy or a natural disaster has put you out of business?	Were you self-employed, but the economy or a natural disaster has put you out of business? Yes	Were you self-employed, but the economy or a natural disaster has put you out of business? No
Have you been dependent on the income of another family member and are no longer supported by that income; and are unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment?	Have you been dependent on the income of another family member and are no longer supported by that income; and are unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment? Yes	Have you been dependent on the income of another family member and are no longer supported by that income; and are unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment? No
Would you estimate that, since December 2007, you have been unemployed for 27 weeks or more in total? Not required to be 27 consecutive weeks.	Would you estimate that, since December 2007, you have been unemployed for 27 weeks or more in total? Not required to be 27 consecutive weeks. Yes	Would you estimate that, since December 2007, you have been unemployed for 27 weeks or more in total? Not required to be 27 consecutive weeks. No

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* 6. If you indicated that you are a recently separated veteran, please indicate your date of separation.

Date of separation:

Date

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* 7. Please complete the following for additional eligibility consideration:

	Yes	No
Do you or someone in your household receive Food Stamps (SNAP):	Do you or someone in your household receive Food Stamps (SNAP): Yes	Do you or someone in your household receive Food Stamps (SNAP): No
Do you or someone in your household receive Welfare Assistance (TANF):	Do you or someone in your household receive Welfare Assistance (TANF): Yes	Do you or someone in your household receive Welfare Assistance (TANF): No

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* 8. Please complete the following for additional eligibility consideration:

Number of family members in household (including yourself):

Approximate household gross income for the past 6 months (includes all contributing members of the household):

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* 9. I certify that the information provided is true and accurate to the best of my knowledge. Please enter today's date

Today's date:

Date

Thank you for completing the pre-eligibility application. If you are determined eligible you will be contacted by your local Business and Career Solutions Center to complete your application and provide the following documentation:
> Valid Driver's License or State ID
> Social Security Card
> Proof of citizenship (birth certificate or passport) may be requested
> Employment history, including dates of employment
> If a male over the age of 18, Selective Service verification
> If a veteran, DD-214

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* 10. Please tell us about your career interests to help us better understand your needs. Also, feel free to let us know if you have any questions or concerns that you would like to have answered by a staff member of the Business and Career Solutions Centers.