Dislocated Worker Program Application

* 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. Incomplete or illegible forms may delay contact.

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 your previous job? *

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

All forms will expire 30 days upon reception. If you do not reply to the Dislocated Worker Program counselor’s attempt to reach you, another interest form will need to be completed.

Dislocated Worker Program Application

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Dislocated Worker Program Application