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ELIGIBILITY PRE-SCREENING
First Name
 Last Name
Date of Birth
Are you legally entitled to work in the United States?
Yes
No
Are you a veteran of the United States Military, or the spouse of a veteran of the United States Military?
Yes
No
Are you homeless?
Yes
No
Have you been convicted of a felony?
Yes
No
Do you receive any of the following public assistance types: SSI, TANF, General Relief, or Refugee Cash Assistance?
Yes
No
Males Only: Have you registered for Selective Service?
Yes
No

ADDITIONAL QUESTIONS FOR NON-WIA PROGRAMS
Are you disabled?
Yes
No
Are you a Native American or Aleut?
Yes
No
Are you a Migrant Farm Worker?
Yes
No

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