Spreadsheet: b3c6aa9d-d47f-4f05-9c88-4e294aeda950
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Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | TRADE ACT PETITION NUMBER: | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
 |  |  |  | [NAME] 1493
 |  |  |  | 217 West 5th Street
 |  |  |  | Spencer, IA 51301
Initial Eligibility Application for Trade Act and/or Workforce Investment Act
I.  GENERAL INFORMATION
[NAME] (Last, First, Middle Initial): |  |  |  |  |  |  | SOCIAL SECURITY NUMBER:
ADDRESS: |  |  |  |  |  |  | GENDER:
 |  |  |  |  |  |  | O  MALE | O  FEMALE | O  UNDECLARED
CITY: |  |  | STATE: |  | ZIP: |  | DATE OF BIRTH  (MM/DD/YY): |  | AGE:
TELEPHONE NUMBER: |  |  | CELL PHONE / ALTERNATIVE PHONE NUMBER: |  |  |  | ETHNICITY  HISPANIC/LATINO:
 |  |  |  |  |  |  | O    YES | O    NO | O  UNDECLARED
E-MAIL ADDRESS:
ARE YOU REGISTERED |  |  | O    YES | RACE (YOU MAY CHECK ONE OR MORE OF THE FOLLOWING):
W/ SELECTIVE SERVICE? |  |  | O    NO | O   NATIVE AMERICAN / ALASKAN NATIVE |  |  |  |  |  | O   PACIFIC ISLANDER / NATIVE HAWAIIAN
 |  |  |  | O   ASIAN / ASIAN AMERICAN |  |  | O  WHITE
U.S. CITIZEN: |  | O    YES | O    NO | O   BLACK / AFRICAN AMERICAN |  |  | O  UNKNOWN / UNDECLARED
IF YOU ARE NOT A U.S. |  | O    YES | IF SO, PROVIDE COPY OF ALIEN REGISTRATION DOCUMENTATION, INCLUDING:
CITIZEN, ARE YOU |  | O    NO | REGISTRATION NUMBER: |  |  |  |  | EXPIRATION DATE:
AUTHORIZED TO WORK
IN THE U.S.?
SEASONAL/MIGRANT WORKER: |  |  | O    NO |  |  | O    MIGRANT FOOD PROCESSOR
 |  |  | O    SEASONAL FARM WORKER |  |  | O    MIGRANT FARM WORKER
II.  VETERAN STATUS
VETERAN STATUS: |  |  |  | CAMPAIGN | O    YES, Eligible Veteran |  | DISABLED | O    YES, Disabled Veteran
O   YES, Served Active Duty < or = to 180 days |  |  |  | VETERAN: | who received medal/badge, |  | VETERAN: | (Service-connected disability resulted
O   YES, [NAME] (Served Active Duty for 180+ days) |  |  |  |  | listed by OPM, for service |  |  | in release from active duty [NAME]
O   YES, Other Eligible Veteran (Spouse of current Veteran) |  |  |  |  |  |  |  | entitlement to compensation; (<30%).)
O    NO |  |  |  |  | O    NO |  |  | O    YES, Special Disabled
TRANSITIONING |  | O    YES, Active military status currently and |  |  | DATE OF MILITARY |  |  | (Rated at 30%+  or 10-20% and
SERVICE |  | either within 24 mos of retirement or |  |  | [NAME] (MM/DD/YY): |  |  | determined to have serious
MEMBER: |  | or 12 mos of separation from armed forces |  |  |  |  |  | employment handicap)
 |  | O    NO |  |  |  |  |  | O    NO
III.  DISABILITY STATUS
DISABILITY: | O    YES, physical or mental impairment |  |  | CATEGORY OF DISABILITY:
 | that limits 1+ major life activities |  |  |  | O    PHYSICAL IMPAIRMENT (including mobility and sensory impairments)
 | O    NO |  |  |  | O    MENTAL IMPAIRMENT (including cognitive and learning impairments)
 | O    UNDECLARED |  |  |  | O    BOTH PHYSICAL AND MENTAL IMPAIRMENTS
IF YES: | O    YES, a barrier to employment |  |  |  | O    UNDECLARED
 | O    YES, but not a barrier to employment
DO YOU HAVE AN INDIVIDUAL EDUCATION PLAN (IEP)?  (YOUTH ONLY) |  |  |  |  |  | O    YES | O    NO
IV.  EDUCATION STATUS AND LANGUAGE SKILLS
TOTAL NUMBER OF YEARS OF EDUCATION: |  |  |  |  | ARE YOU CURRENTLY A FULL-TIME STUDENT? |  |  |  |  | O    YES
 |  |  |  |  |  |  |  |  |  | O    NO
HIGHEST | O       NO SCHOOLING |  |  |  | ARE YOU PLANNING TO ATTEND SCHOOL WITHIN THE |  |  |  |  | O    YES
GRADE | ____   1 TO 12, ENTER GRADE LEVEL COMPLETED |  |  |  | NEXT 4 MONTHS? |  |  |  |  | O    NO
COMPLETED: | O       ATTAINED H.S. DIPLOMA |  |  |  | ARE YOU INTERESTED IN ADDITIONAL TRAINING? |  |  |  |  | O    YES
 | O       ATTAINED GED OR EQUIVALENT |  |  |  |  |  |  |  |  | O    NO
 | O       COMPLETED INDIVIDUAL EDUCATION PLAN (IEP) |  |  |  | TYPE, IF KNOWN:
 | WITH CERT. OF ATTENDANCE/COMPLETION |  |  |  | CURRENT PELL GRANT RECIPIENT? |  |  | SEMESTER/ | YEAR:
 | ____  13 TO 15, ENTER NUMBER OF  FULL-TIME |  |  |  |  |  | O    YES
 | YEARS OF COLLEGE OR TECH/VOC SCHOOL |  |  |  |  |  | O    NO
 | O       ATTAINED OTHER POST-SECONDARY |  |  |  | IS ENGLISH YOUR NATIVE LANGUAGE? |  |  |  |  | O    YES
 | DEGREE OR CERTIFICATION |  |  |  |  |  |  |  |  | O    NO
 | O       ATTAINED ASSOCIATE'S DEGREE |  |  |  | DO YOU HAVE LIMITED ABILITY IN SPEAKING, READING,
 | O       ATTAINED BACHELOR'S DEGREE OR EQUIV. |  |  |  | WRITING, OR UNDERSTANDING THE ENGLISH LANGUAGE AND
 | O       EDUCATION BEYOND BACHELOR'S DEGREE |  |  |  | EITHER:
CURRENT | O   NOT ATTENDING H.S. - DROPPED OUT |  |  |  |  | *ENGLISH IS NOT YOUR NATIVE LANGUAGE
EDUCATION | O   NOT ATTENDING H.S. - GRADUATE |  |  |  |  |  | OR
STATUS: | O   ATTENDING HIGH SCHOOL/ALTERNATIVE H.S. |  |  |  |  | *ENGLISH IS NOT THE DOMINANT LANGUAGE
 | O   ATTENDING GED CLASSES |  |  |  |  | SPOKEN IN YOUR FAMILY/COMMUNITY
 | O   ATTENDING POST-HIGH SCHOOL CLASSES |  |  |  |  |  | O    YES | O    NO
V.  PERSONAL INFORMATION
ARE YOU CURRENTLY EMPLOYED? |  |  |  | O    YES | IF YES, ARE YOU AT RISK OF LOSING |  |  |  | O    YES
 |  |  |  | O    NO | YOUR CURRENT LEVEL OF INCOME? |  |  |  | O    NO
[NAME]:
O  CLAIMANT (NOT REFERRED BY WPRS) |  |  |  | O   EXHAUSTEE |  |  | O   NEITHER CLAIMANT NOR EXHAUSTEE
EMPLOYMENT |  | O    EMPLOYED (INCLUDES ANY WORK AS A PAID EMPLOYEE, ANY WORK FOR YOUR OWN BUSINESS, ANY UNPAID
STATUS AT |  |  | WORK IN A FAMILY BUSINESS, AND A JOB FROM WHICH YOU'VE TEMPORARILY BEEN ABSENT.)
PARTICIPATION: |  | O    EMPLOYED, BUT RECEIVED NOTICE OF TERMINATION OF EMPLOYMENT OR MILITARY SEPARATION
 |  | O    NOT EMPLOYED
HOW MANY FAMILY MEMBERS (INCLUDING YOURSELF) RELATED BY BLOOD, |  |  |  |  |  | HOW MANY DEPENDENTS DO YOU
MARRIAGE, OR ADOPTION LIVE IN YOUR HOUSEHOLD? |  |  |  |  |  | HAVE UNDER THE AGE OF 18?
APPROXIMATE HOUSEHOLD INCOME PER MONTH:
TYPE OF INCOME (Including:  Wages, Self-Emp., Social |  |  |  | MONTHLY AMOUNT |  | FAMILY MEMBER/RECIPIENT
Security, Disability, Child Support, Interest/Dividends, etc)
WITHIN THE LAST 6 MONTHS, |  |  | TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF) OR FIP? |  |  |  |  |  |  | O    YES     O    NO
HAVE YOU RECEIVED THE |  |  | SUPPLEMENTAL SECURITY INCOME (SSI)? |  |  |  |  |  |  | O    YES     O    NO
FOLLOWING: |  |  | SOCIAL SECURITY DISABILITY INSURANCE (SSDI)? |  |  |  |  |  |  | O    YES     O    NO
 |  |  | GENERAL [NAME] (GA), REFUGEE CASH ASSISTANCE (RCA), OR
 |  |  | SUPPLEMENTAL NUTRITION PROGRAMS? |  |  |  |  |  |  | O    YES     O    NO
 |  |  | FOOD STAMPS? |  |  |  |  |  |  | O    YES     O    NO
 |  |  | FOSTER CARE?      TYPE:  __________________________________ |  |  |  |  |  |  | O    YES     O    NO
ADDITIONAL QUESTIONS:
ARE YOU… |  |  |  |  | HAVE YOU EVER BEEN…
PREGNANT OR A PARENT? |  |  | O    YES        O    NO |  | IN FOSTER CARE? |  |  |  |  | O    YES     O    NO
A SINGLE PARENT? |  |  | O    YES        O    NO |  | IN SPECIAL EDUCATION CLASSES? |  |  |  |  | O    YES     O    NO
A HIGH SCHOOL DROP OUT? |  |  | O    YES        O    NO |  | TAKEN INTO CUSTODY? |  |  |  |  | O    YES     O    NO
IN DANGER OF DROPPING OUT? |  |  | O    YES        O    NO |  | CHARGED/CONVICTED OF A MISDEMEANOR? |  |  |  |  | O    YES     O    NO
A RUNAWAY? |  |  | O    YES        O    NO |  | CHARGED/CONVICTED OF A FELONY? |  |  |  |  | O    YES     O    NO
A MIGRANT OR SEASONAL FARM
FAMILY MEMBER? |  |  | O    YES        O    NO
A DISPLACED HOMEMAKER? |  |  | O    YES        O    NO |  | DO YOU…
A VICTIM OR WITNESS OF VIOLENCE |  |  |  |  | HAVE CHRONIC BEHAVIOR PROBLEMS AT SCHOOL? |  |  |  |  | O    YES     O    NO
OR OTHER ABUSE? |  |  | O    YES        O    NO |  | HAVE FAMILY LITERACY PROBLEMS? |  |  |  |  | O    YES     O    NO
HOMELESS? |  |  | O    YES        O    NO |  | HAVE A SUBSTANCE ABUSE PROBLEM? |  |  |  |  | O    YES     O    NO
IF YES, DO YOU LIVE IN A SHELTER? |  |  | O    YES        O    NO |  | LACK OCCUPATIONAL SKILLS/GOALS? |  |  |  |  | O    YES     O    NO
ARE ONE OR BOTH OF YOUR
PARENTS INCARCERATED? |  |  | O    YES        O    NO
VI.  INVOLVEMENT WITH OTHER AGENCIES
PLEASE INDICATE ANY CURRENT AGENCY INVOLVEMENT: |  |  |  |  |  | CONTACT PERSON:
 |  |  | _______ | VOCATIONAL REHABILITATION
 |  |  | _______ | VETERANS' ADMINISTRATION
 |  |  | _______ | PROMISE JOBS PROGRAM
 |  |  | _______ | WORKFORCE INVESTMENT ACT
 |  |  | _______ | TRADE ACT
 |  |  | _______ | PROTEUS
 |  |  | _______ | PROBATION/PAROLE
 |  |  | _______ | WORK RELEASE
 |  |  | _______ | COUNTY RELIEF
 |  | OTHERS: | _______ | _________________________
 |  |  | _______ | _________________________
VII.  EMPLOYMENT-RELATED INFORMATION
DO YOU HAVE A |  | O    YES | DO YOU HAVE ACCESS |  | O    YES | ARE YOU WILLING TO |  |  | O    YES
[NAME] LICENSE? |  | O    NO | TO A RELIABLE CAR? |  | O    NO | RELOCATE FOR WORK? |  |  | O    NO
ARE YOU WILLING TO |  | O    YES | WILL YOU WORK |  | O    YES | WOULD YOU LIKE YOUR RESUME |  |  | O    YES
WORK DOMESTIC JOBS? |  | O    NO | FOR COMMISSION? |  | O    NO | VIEWABLE ON IWD's WEBSITE? |  |  | O    NO
WHAT IS YOUR WORK AVAILABILITY? |  |  |  |  | WHAT SHIFTS ARE YOU AVAILABLE TO WORK?
Full-Time ____    Part-time ____    Seasonal ____   Temporary ____ |  |  |  |  | Day ____      Evening ____      Night ____     Rotating ____      [NAME] ____
WILL YOU WORK ON |  | O    YES | WILL YOU WORK ON |  | O    YES | WHAT IS THE MINIMUM HOURLY
SATURDAYS? |  | O    NO | SUNDAYS? |  | O    NO | WAGE YOU WILL ACCEPT? |  |  |  | ______/hour
[NAME] (starting with the most recent)
NAME OF BUSINESS: |  |  |  |  | LOCATION OF BUSINESS (City, State):
DATES OF EMPLOYMENT |  |  |  |  |  |  | PETITION NUMBER (TRADE ONLY):
From (MM/DD/YYYY): |  |  |  | To (MM/DD/YYYY):
TYPE OF WORK (X one): |  |  |  | HAVE YOU RECEIVED A TERMINATION |  |  | ANTICIPATED LAYOFF DATE:
Full-Time ____    Part-time ____    Seasonal ____ |  |  |  | NOTICE/LETTER? |  | O    YES        O    NO
TYPE OF SEPARATION (X one): |  |  | N/A ____ | LAST HOURLY |  |  | NUMBER OF HOURS WORKED DURING
Total  ____     Partial ____ | Partial ____ |  | Threatened ____ | WAGE RATE: |  |  | LAST FULL WEEK OF WORK:
REASON FOR [NAME] (X one): |  |  |  | If reason for separation was for other than lack of work,  explain:
Lack of Work ___ |  | Other(Specify)___
LAST JOB TITLE: |  |  |  | JOB DUTIES:
NAME OF BUSINESS: |  |  |  |  | LOCATION OF BUSINESS (City, State):
DATES OF EMPLOYMENT |  |  |  |  |  |  | PETITION NUMBER (TRADE ONLY):
From (MM/DD/YYYY): |  |  |  | To (MM/DD/YYYY):
TYPE OF WORK (X one): |  |  |  | HAVE YOU RECEIVED A TERMINATION |  |  | ANTICIPATED LAYOFF DATE:
Full-Time ____    Part-time ____    Seasonal ____ |  |  |  | NOTICE/LETTER? |  | O    YES        O    NO
TYPE OF SEPARATION (X one): |  |  | N/A ____ | LAST HOURLY |  |  | NUMBER OF HOURS WORKED DURING
Total  ____     Partial ____ | Partial ____ |  | Threatened ____ | WAGE RATE: |  |  | LAST FULL WEEK OF WORK:
REASON FOR [NAME] (X one): |  |  |  | If reason for separation was for other than lack of work,  explain:
Lack of Work ___ |  | Other(Specify)___
LAST JOB TITLE: |  |  |  | JOB DUTIES:
NAME OF BUSINESS: |  |  |  |  | LOCATION OF BUSINESS (City, State):
DATES OF EMPLOYMENT |  |  |  |  |  |  | PETITION NUMBER (TRADE ONLY):
From (MM/DD/YYYY): |  |  |  | To (MM/DD/YYYY):
TYPE OF WORK (X one): |  |  |  | HAVE YOU RECEIVED A TERMINATION |  |  | ANTICIPATED LAYOFF DATE:
Full-Time ____    Part-time ____    Seasonal ____ |  |  |  | NOTICE/LETTER? |  | O    YES        O    NO
TYPE OF SEPARATION (X one): |  |  | N/A ____ | LAST HOURLY |  |  | NUMBER OF HOURS WORKED DURING
Total  ____     Partial ____ | Partial ____ |  | Threatened ____ | WAGE RATE: |  |  | LAST FULL WEEK OF WORK:
REASON FOR [NAME] (X one): |  |  |  | If reason for separation was for other than lack of work,  explain:
Lack of Work ___ |  | Other(Specify)___
LAST JOB TITLE: |  |  |  | JOB DUTIES:
NAME OF BUSINESS: |  |  |  |  | LOCATION OF BUSINESS (City, State):
DATES OF EMPLOYMENT |  |  |  |  |  |  | PETITION NUMBER (TRADE ONLY):
From (MM/DD/YYYY): |  |  |  | To (MM/DD/YYYY):
TYPE OF WORK (X one): |  |  |  | HAVE YOU RECEIVED A TERMINATION |  |  | ANTICIPATED LAYOFF DATE:
Full-Time ____    Part-time ____    Seasonal ____ |  |  |  | NOTICE/LETTER? |  | O    YES        O    NO
TYPE OF SEPARATION (X one): |  |  | N/A ____ | LAST HOURLY |  |  | NUMBER OF HOURS WORKED DURING LAST
Total  ____     Partial ____ | Partial ____ |  | Threatened ____ | WAGE RATE: |  |  | FULL WEEK OF WORK:
REASON FOR [NAME] (X one): |  |  |  | If reason for separation was for other than lack of work,  explain:
Lack of Work ___ |  | Other(Specify)___
LAST JOB TITLE: |  |  |  | JOB DUTIES:
VIII.  RECEIPT OF TRADE ACT INFORMATION (TRADE ONLY)
I HAVE RECEIVED A FOLDER OF INFORMATION DETAILING THE TRADE ACT BENEFIT OPTIONS:
O | AT A WORKER INFORMATION/RAPID RESPONSE MEETING |  |  |  |  | O | BY MAIL
O | AT A WORKFORCE OFFICE |  |  |  |  | O
APPLICANT INFORMATION CERTIFICATION
* I give this information to support my request for a determination of entitlement to Trade Adjustment Assistance and Trade Readjustment Allowances under
under the TRADE ACT OF 1974 AMENDED 2002, 2009, and 2011.
 | STATEMENT REQUIRED UNDER THE PRIVACY ACT OF 1974 FOR THE TRADE ACT OF 1974 PROGRAM, AMENDED
Information requested for use by the State Agency and the U.S. Department of Labor is authorized under Sec.231 of the Trade Act of
1974, Amended 2002 and 2007, and Section 806 of the Social Security Act (42 U.S.C. 11061). All information furnished (including Social
Security Account Number) is voluntary and will be confidential except to the extent that release of all such information is authorized
in the processing of this application including income, grades, student progress, attendance, financial aid and status of medical insurance,
and will not be released or used for any purpose other than for establishing entitlement to benefits and allowances under the Trade Act
Program for statistical and research studies and to insure that benefits and allowances have been paid properly.
* I give this information to support my request for a determination of eligibility for Workforce Investment Act services.
* I certify that the information in this application is true and correct including the citizenship status information.  If this information is found to be incorrect,
I understand that I will be responsible for any overpayment and penalty made as a result of that incorrect information and that I may be prosecuted
for fraud.
EQUAL OPPORTUNITY IS THE LAW
It is against the law for this recipient of federal financial assistance to discriminate on the following basis:
·    Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age disability, political affiliation or belief; and
·    Against any beneficiary of programs financially assisted under title 1 of the Workforce Investment Act  of 1998 (WIA), on the basis of the
beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA
Title 1-financially assisted program or activity.
The recipient must not discriminate in any of the following areas:
·          Deciding who will be admitted, or have access, to any WIA Title 1-financially assisted program or activity;
·          Providing opportunities in, or treating any person with regards to, such a program or activity; or
·          Making employment decision in the administration of, or in connection with, such a program or activity.
Equal Opportunity Employer/Program Auxiliary aids and services are available upon request to individuals with disabilities.
SIGNATURE OF APPLICANT |  |  |  |  |  |  |  | DATE
Parent/legal guardian of the above applicant:  I certify by my signature below that the information provided in this application is correct to the best of
my knowledge and that, if accepted, my dependent may participate in employment and training programs.
SIGNATURE OF PARENT/LEGAL GUARDIAN |  |  |  |  |  |  |  | DATE
THIS SECTION IS TO BE COMPLETED BY STAFF
TYPE OF APPLICATION:
WIA Younger Youth
WIA Older Youth
WIA Adult
WIA DW
Iowa Early Intervention Grant (EIG)
Iowa Continuation Emergency Grant (CEG)
National Emergency Grant (NEG)
Trade Act - TAA/TRA |  |  |  |  | REQUIRES:  WAGE A printout and COPY of Alien Registration documentation, if
 |  |  |  |  | applicable.  Send original application along with attachments to State Trade Office
 |  |  |  |  | Keep a copy locally.
STAFF CERTIFICATION
I have discussed with the applicant the statements made within this application.  Based upon my knowledge of the facts, the statements appear to be
correct.
SIGNATURE OF WIA or IWD REPRESENTATIVE |  |  |  |  |  |  |  | DATE
WIA SUPERVISOR'S SIGNATURE |  |  |  |  |  |  |  | DATE
 |  |  |  |  |  |  |  |  |  | REVISED 9.28.12