Dislocated Worker/Adult Interest Form

* Indicates a required field

This program is voluntary. If you are receiving unemployment benefits, enrollment or denial due to program eligibility will not affect your unemployment benefits.

Date *

Month

Day

Year

First Name *

Last Name *

Street Address *

City *

ZIP Code *

County *

Email *

Phone Number *

Veteran or spouse of a veteran?

Yes

No

Most recent: employer and job title *

Select the one that describes your situation:

Laid off

Business closed

Discharged

Quit

Other

Eligible for unemployment insurance?

Yes

No

Exhausted

Do you think you will return to the same industry/occupation? *

Yes

No

Unsure

What assistance do you need to return to work?

Have you worked in the same occupation for 6 months within the last three years? *

Yes

No

How many hours per week were you working? *

How long have you been job searching? *

0-5 weeks

6-14 weeks

15+ weeks

How did you hear about us?

How do I...?

Get help

Apply

Find

File

Pay

Report

Connect with Ramsey County

Breadcrumb menu