Employment Training Application

Name*
First Middle Last
I am a*
- Greensboro Resident
- High Point Resident
- Guilford County Resident
Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address*
Same as previous

Street Address Address Line 2 City State ZIP Code
Phone*
Alternate Phone
Email*

Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Gender
Race/Ethnic Group

Family/Household Members

Name	Relation to the Head of Household	DOB	Last 4 digits of Social Security #	Marital Status (Married, Divorced, Single, N/A)	Gender	Education (Last Grade Completed)

Emergency Contact Information*

Name	Relationship	Address	Phone

Do you have any medical conditions that require a medical or emergency plan?*
- Yes
- No
Please explain your medical condition and share the medical and emergency plan*

Eligibility for emergency assistance is dependent upon the total gross income for you and your household members (relatives only). Please list the total amount grossed in your household within the past 90 days (Do Not Include Non-relatives).
Employment Income in the Past 90 Days
Employment Income 1st Month*
Employment Income 2nd Month*
Employment Income 3rd Month*
Unemployment Benefits in the Past 90 Days
Unemployment Benefits 1st Month*
Unemployment Benefits 2nd Month*
Unemployment Benefits 3rd Month*
Social Security or SSI in the Past 90 Days
Social Security or SSI 1st Month*
Social Security or SSI 2nd Month*
Social Security or SSI 3rd Month*
Pension Income in the Past 90 Days
Pension 1st Month*
Pension 2nd Month*
Pension 3rd Month*
TANF (Work First) in the Past 90 Days
TANF (Work First) 1st Month*
TANF (Work First) 2nd Month*
TANF (Work First) 3rd Month*
Child Support Received in the Past 90 Days
Child Support 1st Month*
Child Support 2nd Month*
Child Support 3rd Month*
Food & Nutrition (Food Stamps) in the Past 90 Days
Food & Nutrition (Food Stamps) 1st Month*
Food & Nutrition (Food Stamps) 2nd Month*
Food & Nutrition (Food Stamps) 3rd Month*
90 Day Income

Employment History

Employer	Address	City	State	Zip Code

Family Type*
- Single Person
- Single Parent
- Two-Parent
- Two Adults-No Children
- Grandparents
Housing Type*
- Own
- Rent
- Public Housing
- Section 8
- Living with family
- Homeless
Please insert a check beside the housing type that best represents your current living arrangements.

Consent for Service Providers*
I Consent to the Release of Confidential Information for Multiple Service Providers
I hereby give my consent for the release of information contained on my application to be released or discussed with other agencies or service providers for the sole purpose of referrals and billing inquires only. By this consent, I shall hold Welfare Reform Liaison Project, Inc. harmless for any liability that I may incur as a result of any disclosure made within the bounds of my consent and authorization.

I understand that my records are protected under 10A NCAC 97B.0302 CONFIDENTIALITY AND DISCLOSURE OF INFORMATION and cannot be disclosed without my written consent unless otherwise provided for in the regulations. The only exception to this requirement is if the disclosure is required by court order or for program monitoring by the Office, authorized federal, state, or local monitoring agencies. I understand that this CONSENT is voluntary, and can be withdrawn/revoked at any time except to the extent that action has been taken in reliance on it, and that in any event, this consent expires automatically as follows:

One year from the date of Consent, unless otherwise specified.
Certification and Waiver*
I agree.
I hereby grant permission and authorize any employer, utility company, fuel company, the Veteran’s Administration, the Social Security Administration, and any other applicable public or private institution to share information regarding my past and present income verification in order to determine eligibility for CSBG services. I allow the release of information contained herein for purposes of verification.

I understand that any personal information I provide will be held in confidence to protect my privacy.

Photo of ID Card*
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 8 MB, Max. files: 2.
Please take a clear photo of your ID or driver’s license
Social Security Card*
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 8 MB, Max. files: 2.
Please take a clear photo of your Social Security Card
Other
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 8 MB, Max. files: 4.
Signature

Employment Training Application

Step 1 of 8

Employment Income in the Past 90 Days

Unemployment Benefits in the Past 90 Days

Social Security or SSI in the Past 90 Days

Pension Income in the Past 90 Days

TANF (Work First) in the Past 90 Days

Child Support Received in the Past 90 Days

Food & Nutrition (Food Stamps) in the Past 90 Days