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 *

Veteran or spouse of a veteran? *

Yes

No

Most recent: employer *

Most recent: job title *

Select the one that describes your situation: *

Laid off or 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? *

Did you work at your previous job for over 2 weeks? *

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?

Email *

Cell phone *

Land phone (if applicable)

How do you want to receive a follow up of your application? (check all that apply):

I agree to receive a follow up email and phone call from an Employment Counselor* to get started with my program eligibility.

I agree to receive a follow up text message from an Employment Counselor* to get started with my program eligibility. I understand that message and data rates may apply.

*The Employment Counselor may be a Ramsey County Employee or a contracted Employment Counselor from a partner agency. Contact will occur within 5 business days.

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