Tennessee Department of Labor and Workforce Development Job Service Registration Form / WIA Application Form Registration Date Social Security Number: --- --- Check all that applies and fill in blanks when applicable. Please PRINT. Name: (Last, First, Middle Initial) Date of Birth: (Month-Day-Year) -- -- Gender/sex: Male Female Email Address Primary Address: Home Work Other Street, Apt. #, PO Box City State Zip County Secondary Contact Person & Information Current Employment Status Name: Employed Street, Apt#, P.O. Box: Unemployed (Seeking Employment) City: State: Zip: County: Not In Labor Force (Not Seeking a Job) Telephone #: Email: Unemployment (UI) Recipient Providing the information in this section below is Voluntary, and is used for statistical purposes: Will you need any special accommodations for employment? Yes No Do you receive SSI or SSDI? Yes No Do you have a Ticket to Work? Yes No Ethnicity: Hispanic or Latino: Yes No Please check all Races that you feel apply to you: Race: White; Black; Asian; American Indian or Alaska Native; Native Hawaiian/Other Pacific Islander *Veterans and Other Eligible s are entitled to Priority of Service. *Veteran or Other Eligible: Yes (or) No Full time National Guards who are mobilized by the State, rather than Federal authorities, are not eligible. Discharge or release must show anything other than Dishonorable. Proof of Veteran Status may be requested. If Yes, supply this information: Served more than 180 days active duty Served 180 days or less on active duty. Branch: Rank at discharge: Dates: Entry: / / Discharge: / / Type of Discharge: Campaign Badge: Yes (or) No Do you have a Service Connected Disability? Yes (or) No, if yes list % Telephone number/s: Home: ( ) - Work: ( ) - Cell: ( ) - Are you a U.S. Citizen: Yes No You will be required to provide identification and evidence of employment eligibility. If you were born after January 1, 1960 please provide your Selective Service Number (if known): Eligible Spouse of Veteran: Yes (or) No Spouse of Veteran who died of service connected disability Spouse of Armed Services member serving on active duty who for total of 90 days missing in action, captured in line of duty by hostile force or forcibly detained in line of duty by foreign government or power. Spouse of any Veteran who has a total disability resulting from service-connected disability, as evaluated by the Dept. of Veteran s Affairs. Spouse of any Veteran who died while a disability was in existence.
Education: In-school, Not In-school; Highest Grade Completed: (numbers of years) Achieved Post Secondary Degree or Certificate: Yes No, If yes Degree/Certificate Type: School/Institution Name: Course Name: Date Completed: Please check any that apply: I am willing to relocate I have an automobile I have other means of transportation, type: I have an occupational license, type: I have tools for my occupation I have a Drivers License I have a commercial Drivers License, class Shift preference: 1 st, 2 nd, 3 rd, any shift What days are you willing to work:? Type of work desired and months experience you have. a. months exp. b. months exp. c. months exp. List any special knowledge, abilities or training you have. What is the minimum starting wage you will accept? $. per (hour, week, month, year) How far are you willing to commute? (One way): miles Please list any machines or tools you can use. In what counties are you willing to accept work:? List your Work History starting with your last job. List those that are most important and lasted the longest. Include military. Company Name and Address: City State Job Title: Dates of employment: from to Rate of pay: Full time or Part Time Describe your duties: Reason for leaving ************************************************************************************************************************************************************************************* Company Name and Address: City State Job Title: Dates of employment: from to Rate of pay: Full time or Part Time Describe your duties: Reason for leaving ************************************************************************************************************************************************************************************* Company Name and Address: City State Job Title: Dates of employment: from to Rate of pay: Full time or Part Time Describe your duties: Reason for leaving ************************************************************************************************************************************************************************************* I believe the information I have provided to be true and accurate. I have presented valid documentation of my identity and proof of my eligibility to work in this country. Signed: Date: Date Customer Staff Signature Date: Parent Signature (if needed) Revised May 2012
Release of Information I hereby authorize the release to/from the Tennessee Career Center Local Workforce Investment Area (LWIA) 10 of any past, present, or future school, employer, medical, or other records that might assist with my individual employment plan. Furthermore, I authorize the Tennessee Career Center (LWIA-10) to use my name, photograph, or information about me in promotional materials, newspaper articles, television interviews, audiovisual presentations, or other public relations and media activities. I have been given an orientation that included: Career Center Services Equal Opportunity is the Law *Grievance Procedures * Release of Information *Authorization of Release of Wage Information By signing below I confirm my understanding of the services and procedures as outlined in the information provided to me and agree to the terms of the above release of information. Customer Signature Career Center Staff Signature Parent s Signature (if under 18) Date Date Date South Central Tennessee Workforce Alliance does not discriminate on the basis of gender, race, color, religion, age, mental or physical activity, veteran status or national origin in educational and employment opportunities. Auxiliary aids and services are available upon request to individuals with disabilities. WIA/LWIA is an Equal Opportunity Employer. Any inquiries and/or complaints should be directed to the Equal Opportunity Officer, South Central Tennessee Workforce Alliance, #8 Courthouse Square, 2 nd Floor, Columbia, TN 38401. Funding is provided under an agreement with the Tennessee Department of Labor and Workforce Development.
"Equal Opportunity Is the Law" It is against the law for the TENNESSEE CAREER CENTER, 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 I 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/her participation in any WIA Title I - financially assisted program or activity. The TENNESSEE CAREER CENTER must not discriminate in any of the following areas: Deciding who will be admitted, or have access, to any WIA Title-I financially assisted program or activity; Providing opportunities in, or treating any person with regard to, such a program or activity; or Making employment decisions in the administration of, or in connection with such a program or activity. If you think that you have been subjected to discrimination under a WIA Title I financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: South Central Tennessee Workforce Board Attn: Suzanne Croft, EO Officer 2 nd Floor, #8 Public Sq. Columbia, TN 38401 Phone: 931/375-4202 TTY/TDD: (931) 388-3869 US Department of Labor Director, Civil Rights Center US Department of Labor 200 Constitution Avenue, NW Room N-4123 Washington, DC 20210 TN Dept of Labor and Workforce Development Attn: EO Officer, Evelyn Gaines Guzman 220 French Landing Drive Nashville, TN 37243 Phone: 615-253-1331 TTY/TDD: 615-532-2879 If you file your complaint with the TENNESSEE CAREER CENTER, you must wait either until the TENNESSEE CAREER CENTER issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the CRC. If THE TENNESSEE CAREER CENTER does not give you written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the TENNESSEE CAREER CENTER to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline. If THE TENNESSEE CAREER CENTER does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. THE TENNESSEE CAREER CENTER is an Equal opportunity employer/program; auxiliary aids and services are available upon request to individuals with disabilities. Participant Name & Date Career Advisor Name Revised May 2010
"La Oportunidad Igual es La Ley" Está en contra de la ley que TENNESSEE CAREER CENTER, un recipiente de la asistencia federal, discrimine sobre la base de lo siguiente: En contra de cualquier individuo en los Estados Unidos, sobre la base de su raza, color, religión, sexo, origen nacional, edad, discapacidad, afiliación política, o creencias; y En contra de cualquier beneficiario de programas ayudado financieramente bajo el Titulo I del Acta de Inversiones de la Fuerza de Trabajo del 1998 (WIA), sobre la base de la condición/ciudadanía del beneficiario como inmigrante admitido legalmente y autorizado para trabajar en los Estados Unidos, o su participación en cualquier programa o actividad ayudado financieramente por el WIA Titulo I. TENNESSEE CAREER CENTER no debe discriminar en ninguna de las siguientes áreas: Decidir quien será admitido, o tendrá acceso, a cualquier programa o actividad ayudado financieramente por el WIA Titulo I; Proveer oportunidades, o tratar cualquier persona con relación a tal programa o actividad; o Tomar decisiones de empleo en la administración, o en conexión con tal programa o actividad. Si usted cree que ha sido sujeto de la discriminación bajo un programa o actividad ayudado con fondos del WIA Titulo I, usted puede poner una queja dentro de 180 días desde la fecha en que se cometió la violación que usted alega con cualquiera de los siguientes organismos: South Central Tennessee Workforce Board Attn: Suzanne Croft, EO Officer 2 nd Floor, #8 Public Square Columbia, TN 38401 Phone: 931/375-4202 TTY/TDD: (931) 388-3869 US Department of Labor Director, Civil Rights Center US Department of Labor 200 Constitution Avenue, NW Room N-4123 Washington, DC 20210 TN Dept of Labor and Workforce Development Attn: EO Officer, Evelyn Gaines Guzman 220 French Landing Drive Nashville, TN 37246-0655 Phone: 615-253-1331 TTY/TDD 615-532-2879 Si usted pone una queja escrita al THE TENNESSEE CAREER CENTER usted debe esperar hasta que THE TENNESSEE CAREER CENTER emita en forma escrita una Noticia de Acción Final, o hasta que hayan pasado 90 días (lo que sea más rápido), antes de poner una queja al CRC. Si THE TENNESSEE CAREER CENTER no le da por escrito una Noticia de Acción Final dentro de 90 días de la fecha en que usted puso su queja, usted no tiene que esperar que THE TENNESSEE CAREER CENTER emita esa Noticia antes de poner una queja al CRC. Sin embargo, usted debe poner su queja al CRC dentro de los 30 días de los 90 días de la fecha de vencimiento. Si THE TENNESSEE CAREER CENTER le da por escrito una Noticia de Acción Final en su queja, pero usted no esta contento con la solución o resolución, usted puede poner una queja al CRC. Debe ponerla dentro de 30 días de la fecha en que usted recibió la Noticia de Acción Final. THE TENNESSEE CAREER CENTER es una agencia de trabajo y/o un programa de Oportunidad Igual; las ayudas y los servicios auxiliares están, por petición propia, a la disposición de los individuos con discapacidades. Nombre y Fecha Career Advisor
Dislocated Worker Eligibility Name SS # 1. Have you been terminated or laid off or received a notice of termination within the last five years? YES NO 2. Are you currently receiving unemployment insurance benefits? YES NO 3. Have you received unemployment insurance benefits at any time during the last five year but are no longer eligible to receive those benefits (UI claim is exhausted)? YES NO 4. Was your application for unemployment benefits denied? YES NO 5. Do you have a spouse that has been permanently laid off or who retired due to a plant closing or major downsizing? YES NO 6. Have you experienced a divorce or death of a spouse that has resulted in the loss of income that you were dependent on for your livelihood? YES NO 7. Have you worked with an employer that has permanently closed or has announced that they will be closing, or has announced a major downsizing that will result in permanent layoffs? YES NO 8. Have you been self-employed, but are now unemployed due to general economic conditions? YES NO Customer Signature and Date The above applicant statement is being utilized to determine eligibility for dislocated worker status. Signature and Date of Eligibility Official
Additional Work History List additional work history that was not included on your Job Service Registration/WIA Application Form. Include month, day and year for each time worked. Company Name and Address: City State Job Title: Dates of employment: from- to- Rate of pay: Full time or Part Time Describe your duties: Reason for leaving Company Name and Address: City State Job Title: Dates of employment: from- to- Rate of pay: Full time or Part Time Describe your duties: Reason for leaving Company Name and Address: City State Job Title: Dates of employment: from- to- Rate of pay: Full time or Part Time Describe your duties: Reason for leaving Company Name and Address: City State Job Title: Dates of employment: from- to- Rate of pay: Full time or Part Time Describe your duties: Reason for leaving Company Name and Address: City State Job Title: Dates of employment: from- to- Rate of pay: Full time or Part Time Describe your duties: Reason for leaving Company Name and Address: City State Job Title: Dates of employment: from- to- Rate of pay: Full time or Part Time Describe your duties: Reason for leaving
National Emergency Grant (NEG) OJT Eligibility Screener Customer Name: SS# 1. Were you laid off on or after January 1, 2008? Yes No 2. Have you been unemployed for 19 weeks or more? Yes No 3. Were you laid off from or were you working for a company that closed? Yes No 4. Are you currently drawing Unemployment or have you exhausted Unemployment? Yes No 5. Are you an individual who was self-employed (including employment as a farmer, a rancher, or fisherman) but is unemployed as a result of general economic conditions in the community in which the individual resides or because of natural disaster? Yes No 6. Please answer the following: a. Are you an individual who has primarily worked as a homemaker providing unpaid services to family members in the home? Yes No b. Have you been dependent on income of another family member, but have lost that source of income due to divorce, death of family member, of layoff of family member? Yes No c. Are you unemployed or underemployed? Yes No I believe the information I have provided to be true and accurate. I understand that I will be required to provide proof of the above information. Date: Date Customer Signature Staff Signature
Full Name: SSN: Last four digits: Registration Date: Funding Source: SECTION I: PREVIOUS EDUCATION & TRAINING School or Training Provider: Diploma / Degree / Certificate: Dates Attended: Career Readiness Certificate Date Administered: Level Achieved: Career Scope Date Administered: Top Work Group Recommendations (Areas with both interests and aptitude) 1. 2. 3. TABE Scores Date Administered: READING Scaled Score GE LANGUAGE Scaled Score GE TOTAL MATH Scaled Score GE OTHER ASSESSMENTS 1. Date Administered: 2. Date Administered: 3. Date Administered: SECTION II: EMPLOYMENT AND RELATED GOALS Short Term Goal: Long Term Goal:
SECTION III: WORK HISTORY (Attach a copy of the WIA Registration (Intake) work history and additional work history form.) SECTION IV: BARRIERS TO EMPLOYMENT (Must check at least one) 1. 2. 3. 4. 5. Transportation Childcare Lacks H.S. Diploma / G.E.D. Basic Skills deficient Limited work history Poor work history Chemical Dependency Lacks basic computer skills Health / Medical Skills do not match current job market Not self-sufficient with current employment Unemployed or underemployed Criminal Background Other ( please list all below ) SECTION V: SKILLS & STRENGTHS 1. 2. 3. 4.
Section VI: ACTION STEPS AND SUPPORTIVE SERVICES (Please Check All That Apply) Core Services: X Complete Intake & Orientation to Services Other: Core and/or Intensive Services Complete Assessments: Career Scope Work Keys Review of Work History & Skills with Career Advisor Other: Individual Counseling & Career Planning Complete Career Search Worksheet Job Shadow Occupational Interviews Other: Job Readiness 1. 2. 3. Complete Interview Stream Attend Workshops listed below:. Give Copy of Completed Resume to Career Advisor Other: Job Search Assistance Register with TDOL & Workforce Development Job Service Turn in Weekly Job Logs Job Referrals Other: Pre-Vocational Services 1. 2. Attend Study Skills For Academic Success Complete FAFSA & Items on Training Checklist Other: Person Responsible Customer & Staff Projected Completion Date
Training Services: Training Services Training Provider / Program Studies: Person Responsible Projected Completion Date Funding Source On The Job Training Employer: Adult Education Other: 1. 2. 3. Supportive Services (must have barrier checked above): 1. 2. 3. 4. 5. Referrals to Other Resources: 1. 2. 3. Follow-Up Complete Quarterly Follow-Up Contacts after Completion of Goals 1. 2. Other:
I have met with Career Center staff to develop this plan and agree to complete all assigned activities. I agree to maintain monthly contact with Career Center staff. If I am attending training, I agree to meet the academic and attendance requirements of the training provider and to provide Career Center staff with copies of my transcript or progress/attendance reports at the end of each term. I agree to contact my Career advisor should issues arise that interfere with my training or job search. I understand that all services available through the Career Center are contingent upon availability of funding and my meeting all eligibility requirements. I understand that there will be a one year follow-up after I have completed program goals. I agree to complete all follow-up surveys. Customer Signature Date Staff Signature Date
INDIVIDUAL EMPLOYMENT PLAN AMENDMENTS Date Customer Signature Staff Signature IEP AMENDMENTS Revised 5/15/12
SOUTH CENTRAL TENNESSEE WORKFORCE ALLIANCE DEMOGRAPHIC INFORMATION Customer Name Last 4 digits of SS# Please check all that apply to you below so that you may be notified of special funding and services that may be available to you: Race/Ethnicity Hispanic American Indian White Black Native Hawaiian Asian Hispanic/Latino Education Details: High School Dropout Received GED Limited English Employment Details: Most Recent Job Title Most Recent Job Begin Date Average Hours per Week Hourly Wage Disability Info: Checking any of these in this section could make you eligible for additional benefits through the career center or youth program. Do you have a disability (includes learning)? Yes No Type of Disability Special Accommodations Needed If you are a high school student, do you have a 504 plan or IEP? Yes No Have you ever received Social Security Disability Insurance (SSDI)? Yes No Are you currently receiving: SSDI SSI Do you have a Ticket to Work? Yes No Have you seen a Vocational Rehabilitation Counselor? Yes No Please check the things that you think make it hard for you to get a job: Limited Education Work History/Experience Ex-offender Substance Use Language Barrier No child care Homeless Disability Please check the benefits that you had on your most recent job: Health Vacation Sick Leave Flexible Work Schedule Telework None Customized Employment Job Sharing Other (please list):
(over) Displaced Homemaker: Have you been providing unpaid services to family members in the home and have been dependent upon the income of another family member but you are no longer supported by that income (due to divorce, death, or layoff of spouse)? Yes No Are you unemployed? Yes No If employed, what is your hourly wage? If employed, how many hours per week do you work? Do any of the following apply to you: Have you received a traffic ticket? Yes No Have you been charged with a misdemeanor? Yes No Have you been charged with a felony? Yes No Foster Child Homeless Receiving food stamps Currently receiving welfare payments (Families First or TANF-Temporary Assistance to Needy Families) Single Parent Pregnant Youth (21 and under) Are you registered for job search assistance with Tennessee Dept. of Labor? Yes No Please list all individuals living in your household: Name Relationship Date of Birth Monthly Income Revised 7/20/12
South Central Tennessee Workforce Alliance Tennessee Career Center GRIEVANCE PROCEDURE Statement of Policy The following grievance procedure will be used to address all client, contractor, or employer grievances; as such, a grievance shall be defined as any violation of the Civil Rights Act of 1964 or Section 188 of the Workforce Investment Act as amended. These statutes guarantee that no person, on the ground of age, political affiliation or belief, disability, race, color, religion, sex, or national origin, and for beneficiaries only, citizenship or participation in activities through the South Central Tennessee Workforce Alliance/Tennessee Career Center shall be excluded from participation in or discriminated against or denied the benefits of any program under the Workforce Investment Act. A grievance may be filed by Tennessee Career Center job seeker, employer, or applicant for participation in a program who believes discrimination or unfair treatment has been practiced against him/her, or any contractor or employer who feels that the career center practices or procedures have or will result in discrimination against them. Grievance Procedure Should a job seeker, customer, contractor, or employer have reason to believe that they have been treated unfairly, they should take the steps outlined below. 1. Efforts must first be made by the individual to resolve the differences with the person or persons responsible for such alleged discrimination or mistreatment. 2. In the event a grievance cannot be resolved as provided in (1.) above, the grievance must be submitted to the Equal Opportunity (EO) Compliance Officer for the South Central Tennessee Workforce Alliance, who will review the grievance and determine the appropriate process. All grievances must be in writing and contain the name and address of the individual, description of specific evidence of discrimination or mistreatment, be signed by the individual, and be filed within 180 days of the alleged occurrence except for a complaint/grievance alleging fraud or criminal activity. 3. The Equal Opportunity Compliance Officer for the South Central Tennessee Workforce Alliance shall conduct an investigation and present findings and recommendations to the Executive Director of the South Central Tennessee Workforce Alliance within ten (10) working days of receipt of the grievance. 4. The Executive Director of the South Central Tennessee Workforce Alliance shall review the findings and recommendations and make a final determination of outcome within thirty (30) working days. If the grievance is not resolved under these procedures (indicated in 2-4 above) satisfactorily to the individual, or the
decision is adverse, or the decision is not made within sixty (60) days of the filing, the individual, or his or her representative, may file a complaint with the Director, Civil Rights Center, within thirty (30) days of the recipient level decision or ninety (90) days from the date of filing the grievance, whichever is earlier. 5. Any person who believes himself, or herself, or any specific class of individuals to be subject to discrimination prohibited by Section 188 Public Law 105-220 of the Workforce Investment Act of August 7, 1998, Title VI the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 and the Americans with Disability Act of 1990, Title IX of the Education Amendments of 1972, and the Age Discrimination Act of 1975, may, by himself or herself, or by a representative, file a written complaint With the Directorate of Civil Rights, U.S. Department of Labor, 200 Constitution Avenue NW, Washington, D.C. 20210. The complaint must be filed no later than 180 days from the date of the alleged discrimination, unless the time for filing is extended by the Regional Director of the Office of Civil Rights, Exhaustion of the Local Workforce Investment Act grievance procedures is not a prerequisite for filing a complaint alleging discrimination under Title VI of the Civil Rights Act of 1964. 6. The procedures and forms needed for state and federal review, non-criminal grievance, non- South Central Tennessee Workforce Alliance/Tennessee Career Center remedies and discrimination on the basis of disability, race/color, etc., can be obtained from the South Central Tennessee Workforce Alliance in Columbia, Tennessee. The address is as follows: South Central Tennessee Workforce Alliance ATTN: Suzanne Croft, EO Officer 2nd Floor, #8 Courthouse Square Columbia, TN 38401 (931) 375-4202 TTY# (931) 388-3869
AUTHORIZATION FOR RELEASE OF WAGE INFORMATION I authorize the Tennessee Department of Labor and Workforce Development to release my wage information, as reported by my employers for unemployment premium purposes, to Workforce Investment Act Partners under the following conditions: 1) The identity of my employer(s) will not be revealed, and 2) The information will be used solely for the purpose of confirming the wage information I have provided in connection with my desire to obtain Intensive WIA Services and for tracking my future wages. I understand that my failure to authorize the disclosure of this information cannot be used as a basis for denying access to these services. Signature of Applicant Date Signature of LWIA Representative Date Signature of TDLWD Representative Date