I. APPLICANT INFORMATION
Last Name First Name Middle Initial
Last 5 Digits of SS# XXX-X Date of Birth Age
Street Address
CityState Zip Code
County Phone Mobile Email
Gender: Male Female  
Ethnicity: American Indian/Alaskan Native Asian Black/African American Caucasian Hawaiian Native/Pacific Islander Hispanic/Latino Multicultural
Marital Status: Single Married Divorced Separated Widowed
Number of dependents Age(s) of Children
Check any of the following that apply to you:
     School Dropout Parent or Pregnant Disabled Offender
     Foster Child Homeless or Runaway 

II. INCOME INFORMATION

Please specify the # of family members living in your household AND check your approximate annual gross family income:

$1 - $10,400 $10,401 - $14,000 $14,001 - $18,243

$18,244 - $22,523 $22,524 - $26,583 $26,584 - $31,089

$31,090 - $35,595 $35,596 - $40,101 $40,102 +

What is your family's approximate gross monthly income?
With whom do you live? (Check all that apply)
    Alone Parents Child(ren) Spouse Other
Indicate the monthly amount your household receives from each of the following:
    FI/TANF Food Stamps ABC Child Support
    SSI Unemployment VA Benefit Other

III. EDUCATIONAL INFORMATION
What is your educational/Career goal?
Highest education level: No High School Diploma High School Certificate High School Diploma GED Some College AS Degree Vocational Certificate List vocational certificates:
Highest grade completed if you did no graduate from high school?  
Are you currently attending a GED prep course? Yes No   Where?
Have you attended or are you currently attending college/training? Yes No
    If "Yes" list name of school
    Dates of Enrollment List Program
    Current GPA
   If you did not complete it, please list reason:
Have you previously participated in a WIA program? Yes No
If yes, please list when, where and the name of your case manager/consultant:

IV. EMPLOYMENT INFORMATION
Employment Status: Full Time Part Time Unemployed Seeking Employment
Last Employer Address
    City/State/Zip Code Phone
    Job Title
    Job duties
    Hourly Wage Hours Per Week Start Date End Date
    Reason for leaving

 Previous Employer Address
    City/State/Zip Code Phone
    Job Title
    Job duties
    Hourly Wage Hours Per Week Start Date End Date
    Reason for leaving

 Previous Employer Address
    City/State/Zip Code Phone
    Job Title
    Job duties
    Hourly Wage Hours Per Week Start Date End Date
    Reason for leaving

V. ALTERNATE CONTACT INFORMATION (Please provide information on someone not in your household)
Name Relationship
Address/City/State/Zip Code
Phone Mobile Work Work Email

VI. PERSONAL STATEMENT
Please write a brief statement indicating why you want to participant in the Workforce Investment Act (WIA) 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 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 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.