*1.Understanding of Participation Requirements 
The purpose of the City of Alexandria Upskilling Program is to assist participants in gaining the knowledge, skills, and work experience needed to obtain a higher paying job.
 
I understand that there are eligibility requirements and that if I participate in the Upskilling Program, I will communicate regularly with program staff who will assist me in meeting my employment goals.  If yes, please continue to complete the form.(Required.)

Yes

No

*2.Today's Date (MM/DD/YYYY)(Required.)

*3.Full Name(Required.)

*4.Contact Information(Required.)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

*5.Best way to contact you(Required.)

*6.Date of Birth MM/DD/YYYY(Required.)

*7.Are you eligible/authorized to work in the United States?(Required.)

Yes

No

*8.Are you a veteran of the United States military?(Required.)

Yes

No

*9.What is the primary language you speak at home?(Required.)

*10.Do you need English translation assistance?(Required.)

Yes

No

*11.Do you need English as a Second Language (ESL) classes?(Required.)

Yes

No

*12.“Federal law requires employers and American Job Centers to provide reasonable accommodation to qualified individuals with disabilities. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment”. 

Do you require a reasonable accommodation to apply for a job or to perform your job?(Required.)

No

Yes (Please specify below.)

*13.Do you receive any of the following benefits/public assistance? (If Yes, please select all that apply.  If No, please select N/A.):(Required.)

N/A

Medicare

Medicaid

SSI (Supplemental Security Income)

SSDI (Social Security Disability Insurance)

TANF (Temporary Assistance for Needy Families)

SNAP (Supplemental Nutrition Assistance Program)

SNAPET (Supplemental Nutrition Assistance Program Employment and Training)

WIOA (Workforce Innovation & Opportunity Act)

VIEW (Virginia Initiative for Education and Work)

Public Housing

Other (please specify)

*14.Are you currently employed?(Required.)

Yes

No (Please enter your last day of work below.)

*15.Are you receiving Unemployment Insurance (UI) benefits?(Required.)

No

Yes (Please enter the date of your termination letter below.)

*16.Have you received Unemployment Insurance (UI) benefits in the past?(Required.)

No

Yes (Please enter dates you received UI benefits below.)

*17.What is your highest level of education?(Required.)

*18.Are you pregnant or parenting?(Required.)

Yes

No

*19.Have you ever been in Foster Care?(Required.)

Yes

No

*20.Are you experiencing homelessness?(Required.)

Yes

No

*21.How many people live in your household?(Required.)

*22.What is your approximate annual household income?(Required.)

Less than $12,000

Less than $20,000

Less than $25,000

Less than $29,000

Less than $38,000

More than $38,000

*23.Tell us about your work experience.(Required.)

*24.Tell us what training you think would help you obtain a higher paying job.

(Required.)

*25.Tell us why this training will help you.(Required.)