I. APPLICANT INFORMATION
1. Last Name First Name Middle Initial
2. Social Security Number Date of Birth Age
3. Street Address
    CityState Zip Code
4. Mailing Address
    City State Zip Code
5. County Phone Mobile Email
6. Sex: Male Female Are you a citizen? Yes No
7. Draft Status (males only): Registered Not Registered N/A
8. Race: American Indian/Alaskan Native Asian Black/African American Caucasian Hawaiian Native/Pacific Islander Hispanic/Latino Multicultural
9. Marital Status: Single Married Divorced Separated Widowed
10. Number of children Age(s) of Children
11. Check any of the following that apply to you:
     No Work History School Dropout Parent or Pregnant Disabled Offender
     Foster Child Homeless or Runaway Public Housing Substance Abuse
     Faces Serious Barriers to Employment

II. EMPLOYMENT INFORMATION
1. Employment Status: Full Time Part Time Unemployed Seeking Employment
2. Employer Address
    City/State/Zip Code Phone
    Job Title Supervisor’s Name
    Briefly describe your job duties
    Hourly Wage Hours Per Week Start Date End Date
    Reason for leaving

III. HOUSEHOLD INCOME INFORMATION
1. Size of family (# of people living in your household)
2. With whom do you live? (Check all that apply)
    Alone Both Parents Mother Father Child(ren) Spouse
    Relative Relative Name (If applicable) Legal Guardian Friend(s) Other
3. Below you must list all family members with whom you live. Make sure to list ALL social security #’s, income, sources of income and relationship to that individual.

Name of Family Member	Social Security Number	Relationship	Monthly Income Before Deductions	Employer

4. Indicate the monthly amount your household receives from each of the following:
    TANF Food Stamps Child Support Alimony
    Disability Social Security VA Benefit Other

IV. EDUCATIONAL INFORMATION
1. What is your educational goal?
2. Education level: No High School Diploma High School Diploma High School Certificate GED Some College Technical Degree
    If Technical Degree selected above, name of degree:
3. Name of High School Dates of Attendance
4. Are you currently enrolled in a technical college, vocational college or a four-year institution? Yes No
    If “yes”, list the name of school Date of Enrollment
    List Program of Study Current GPA
5. Have you ever attended a technical college, vocational college or a four-year institution? Yes No
    If “yes”, when? List name of school
    List Program Did you complete the program of study? Yes No
    If “no”, please list reason for not completing

V. CONTACT INFORMATION
Name Relationship
Address/City/State/Zip Code
Phone Mobile Work Email

VI. PERSONAL STATMENT
Please write a brief statement indicating why you want to participant in the Workforce Investment Act (WIA) Older Youth Program. Include what you hope to gain through your participation with the program.

VII. SIGNATURE OF CERTIFICATION
By pressing the "Submit" button below, you are stating that you have read and agreed to all the following statements. 

1. I understand that the completion of the application does not guarantee acceptance into the WIA Older Youth Program.
2. I certify that the information provided on this application is true and correct to the best of my knowledge.
3. I understand that ANY information provided that is falsified will disqualify me from participating in the WIA Older Youth Program at Midlands Technical College.
4. I authorize the College to release my educational, academic, financial, and other pertinent information to the WIA staff.
5. I understand that the information provided on this application will be held in strict confidence by WIA/College staff.