IDENTIFICATION One (1) Item from List A OR One (1) Item from List B AND One (1) Item from List C Provide verification for the following identification: List A  United States Passport  Certificate of United States Citizenship  Certificate of Naturalization  Unexpired Foreign Passport w/Attached Employment Authorization  Alien Registration Card w/Photograph List B  State issued Driver’s License or State I.D. Card w/Picture or Information (Name, Sex, Date of Birth, Height, Weight & Color of Eyes)  U.S. Military I.D. Card AND List C  Original Social Security to be Witnessed at Intake  Certificate Issued by State, County or Municipal Authority  Unexpired INS Employment Authorization What is your highest level of education? Check one: No formal schooling Some elementary school (grades 1-8) Some high school (grades 9-12) but no high school diploma Special education certificate of completion/attendance High school diploma GED (high school equivalency certificate) Name of High School Some college/vo-tech – No degree Present Vocational/Technical Certificate Associate Degree Bachelor’s Degree Master’s Degree or Higher College/Vo-Tech Schools : Name of School: Address of School : How can the Bureau be of assistance to you? What employment related services are you seeking: Are you working? If yes, where: If no, check one: H.S. Student Other Student Trainee/Intern/Volunteer Other Not Employed If you are employed, how many hours do you usually work per week? If you are employed, what are your current WEEKLY earnings? $ (gross wages, salaries, tips or commissions before payroll or tax deductions)
Are you currently receiving any of the following? If yes, please list the MONTHLY amount. SSDI (Social Security Disability Insurance) Amount: $_ General Assistance (Public Assistance) Amount: $_ SSI (Supplemental Security Income) Amount: $_ Veterans’ disability benefits Amount: $ TANF (Temporary Assistance for Needy Families) Amount: $ Any other public support Amount: $ Workers’ compensation Amount: $ (Please describe)_ Do you have any of the following types of medical insurance coverage? Check one or more:  Medicaid  Medicare  Workers’ Compensation  Private insurance through employment  Insurance Company  No Medical Insurance Coverage  Other Public Insurance Private insurance through other means: (for example, insurance through your parents or spouse) To help us coordinate your services, please check any other services you are receiving. Check one or more if you are receiving the following: Temporary Assistance (TANF) $ General Assistance (GA) $ Food Stamps $ Children and Family Services Foster Care Child Support Enforcement Child Care Adult Protective Services Low Income Energy Assistance Medicaid Working Healthy Other None COMMUNICATION ACCOMMODATIONS Regular print Braille language (specify) Large print While in school, did you ever have an Individualized Education Program or IEP (special education)? YES NO What is your primary means of transportation? Personal Vehicle Public Transportation Other Have you ever been convicted of a felony? Yes No Details: Probation Officer: # ( )