Intake

Information DO NOT Remove

From Folder

Without written consent of CareerSource Escarosa’s

Executive Director

Street City State Zip

Last First (MI)

Interest Application All information for CareerSource Escarosa use only!

Under The Applicable Provisions Of The Privacy Act Of 1974, I hereby certify, that I have not withheld any information that could affect the services that I may receive through the CareerSource Escarosa and that, to the best of my knowledge, all of the above information is true and correct. I understand any willful misstatement of facts may cause forfeiture of program eligibility and that false information related to my efforts to receive Unemployment Compensation may be subject to penalties under Florida law. I also understand that the above information is subject to verification, and will be handled by Workforce Escarosa, staff as “Confidential”, and may be shared with other partners and/or federal, state, and/or local government/non-government agency/organizations on a strict “need to know” basis. I agree to provide any additional documentation that may be required to assess my needs relevant to CareerSource Escarosa /partner program services.

Under the Americans with Disabilities Act, the Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service, or activity. For example, this means that if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know your disability needs in advance if at all possible. Please contact your local CareerSource Escarosa One-Stop Center. Equal Opportunity Employer/Program

Last Employer: Dates: Hourly Rate: Briefly Describe Work Performed:

City:

State:

From:

To:

Starting Pay:

Final:

Reason for Leaving:

Last Employer: Dates: Hourly Rate: Briefly Describe Work Performed:

City:

State:

From:

To:

Starting Pay:

Final:

Reason for Leaving:

WIA Applicant Authorization

to Request and/or Release Information

Applicant Name

I hereby authorize CareerSource Escarosa and/or its WIA Program Service Providers to request and release information pertaining to my records/reports, which is relevant to my participation in the CareerSource Escarosa WIA Programs and/or follow-on employment. I understand that this authorization may pertain to one or more of the following organizations.

Division of Vocational Rehabilitation Department of Children and Families Division of Workers Compensation Division of Unemployment Compensation School(s) (e.g., primary, secondary, university, college, vocational institutions) Hospital(s), Clinic(s), Physician(s) Lakeview Center Law Enforcement Agencies Past/Prospective Employer(s) Other: ________________________

I understand that:

CareerSource Escarosa and/or its WIA service providers will request and/or release information only to assist them with determining appropriate training activities and supportive services or to assist me with obtaining unsubsidized employment after I complete my training/job search activities;

Information collected will be shared only upon request from authorized entities and then only on a strict need-to-know basis;

In accordance with state and federal laws, information may be provided to state and federal auditors, monitors, and agents; CareerSource Escarosa or the WIA service provider will record each occasion of a request/release in my WIA file,

documenting the date, other entity (ies) involved, and type of information requested/released; I may make an appointment with my WIA point-of-contact to review those occasions; All information will remain confidential within all authorized agencies.

Finally, I understand that this signed authorization remains in effect through the thirteenth month after my WIA file is close or my WIA eligibility expires.

Information Requested: _________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Applicant Signature & Date Parent/Legal Guardian Signature & Date

Certifying Official Signature & Date

Partner Agency/Organization Statement of Purpose for Collecting Social Security Numbers

Applicant Name: ______________________________________ House Bill 673 [s. 119.072(9) F.S.] requires agencies collecting social security numbers to provide customers/program participants with a written Statement of Purposes for such collection. To ensure confidentiality of the participant’s records, CareerSource partner staff will not provide participant social security numbers to persons, agencies, and organizations outside the Regional Workforce Board #1 (RWB1), CareerSource Escarosa umbrella. This restriction includes private vendors. On the rarest of occasions, staff may find a need to provide private social security numbers to specific vendors. Before doing so, however, staff must obtain a written Statement of Purposes from the person or entity requesting the social security number, a signed Release of Information from customer/participant, and advance approval to release the social security number(s) from the CareerSource Escarosa Executive Director or Assistant Director. I understand that the CareerSource Escarosa partner staff requires the social security number(s) to:

Register customers/participants with our One-Stop Career Centers

Coordinate services with other RWFB 1 CareerSource Escarosa agencies, organizations, and entities.

Assess customers for program eligibility an services

Enroll participants into specific programs

Provide and record program services

Track participants activity outcomes

Measure CareerSource Escarosa performance standards

Support Federal/State customer service survey requirements.

CareerSource Escarosa partner staff with treat all participant information as CONFIDENTIAL. This Statement of

Purposes will be attached to the customer/participants One-Stop Universal Application/Registration Form and

placed in the participant’s file. A copy should also be given to the customer/participant.

Customer/Participant Signature Date

CareerSource Escarosa Staff Signature Date

POLICY STATEMENT ON SEXUAL HARASSMENT

CareerSource Escarosa respects every individual's right to be free from uninvited verbal or physical conduct of a sexual nature. The Federal Equal Employment Opportunity Commission

(EEOC) guidelines and the Department of Management Services' administrative rule defines sexual harassment as follows:

Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature from any person when:

Submission to such conduct is either explicitly or implicitly a term or condition of an

individual's employment; Submission to or rejection of such conduct by an individual is used as the basis for

employment decisions affecting such individual; Such condition has the purpose or effect of unreasonably interfering with an individual's

work performance or creating an intimidating, hostile, or offensive working environment.

Sexual harassment includes unwelcome verbal behavior such as comments, suggestions, jokes, or derogatory remarks based on sex; physical behavior such as pats, squeezes, repeatedly brushing against someone's body, or impeding or blocking normal work or movement; visual harassment such as posting of sexually suggestive or derogatory pictures, cartoons or drawings, even at one's own work station; unwanted sexual advances, pressure for sexual favors and/or basing employment decisions (such as an associate's performance evaluation, work assignments or advancement) upon the associate's acquiescence to sexually harassing behavior.

Title IX of the Education Amendments of 1972 extends protection under federal law to participants in educational and training programs receiving federal financial assistance. CareerSource Escarosa policy classifies sexual harassment as conduct unbecoming a CareerSource Escarosa employee, and employees who violate the policy are subject to disciplinary action.

CareerSource Escarosa will protect all employees, to the extent possible, from harassment in the workplace, and ensure that customers of CareerSource Escarosa receive the services they need absent of verbal or physical harassment. CareerSource Escarosa will exercise zero tolerance for sexual harassment, and all reported allegations of inappropriate conduct will be promptly and thoroughly investigated.

Date Executive Director CareerSource Escarosa

Workforce Investment Act (WIA) ADULT & DISLOCATED PROGRAMS

OCCUPATIONAL SKILLS TRAINING AGREEMENT This agreement outlines policies, guidelines and rules concerning your participation in the WIA Adult or Dislocated

Worker funded Occupational Skills Training (OST) Program. Be sure to read this document thoroughly and ask your

WIA Career Advisor for clarification as needed. Failure to comply fully with this agreement may result in your

termination from Workforce ESCAROSA training program.

1. WIA-funded OST will not normally exceed two years in duration. Upon successful completion of training in the

occupational area as agreed to by Career Source ESCAROSA, you agree to seek and obtain employment in a

training related field.

2. To qualify/remain qualified for WIA assistance, you must:

a. Agree to participate in a Career Source ESCAROSA approved training program; .

b. Sign a WIA "School Information Release" form authorizing the educational institution to share

attendance records, grades, and student aid information with WIA staff;

c. Have your training schedules pre-approved by your WIA Career Advisor prior to registering for classes

each term/semester;

d. Obtain written referrals to the on-campus representative (e.g., financial aid office, registration counselors,

book store, etc.) from your WIA Career Advisor prior to making those visits/conducting such business;

e. Satisfy all school prerequisites (e.g., academic requirements, first time/initial enrollment fees, if applied

by the institution) and properly register for all WIA Career Advisor approved classes prior to each

term/semester;

f. Start and attend all classroom training in accordance with institution schedules, procedures, and policies;

g. Attend classes full time (i.e., at least 9 credit hours per term (college) or minimum 20 clock hours per

week (vocational training center). Exceptions must be pre-approved by your WIA Career Advisor;

h. Maintain a minimum 2.0 (“C”) Grade Point Average throughout your training;

i. Complete and submit monthly WIA Class Attendance Reports to your WIA Career Advisor in a timely

manner; and

j. Maintain minimum monthly contacts with your WIA Career Advisor via office visits’, email and/or

telephone communications, keeping him/her apprised of your academic progress and personal situation

and assisting with federal, state, and local WIA administrative requirements. FAILURE TO COMPLY

WITH THIS MAY RESULT IN TERMINATION FROM THE WIA PROGRAM.

3. All WIA sponsored participants enrolling into/attending long term OST programs (six months or longer) must

apply for PELL Grants each academic year. If you are eligible for the PELL Grant, these funds may be used to

apply toward any tuition or books not covered by WIA or may be used to assist you with living expenses while

attending training. Your Career Advisor will discuss your financial needs with you to determine how PELL funds

will be best used to support your training activity.

4. Career Source Escarosa OST funding will be applied through an Individual Training Account (ITA) voucher. The

maximum value of a Workforce Escarosa ITA voucher will be established by the Workforce Development Board

of Directors for Region I (Escambia and Santa Rosa Counties, Florida). ITA vouchers are issued to WIA

participants enrolling into pre-approved OST programs. Participants present their ITA vouchers to educational

institutions. The educational institution collects actual tuition fees and book costs via vouchers. ITA transactions

are between Career Sourrce ESCAROSA and authorized educational institutions. ITA’s do not provide cash to

participants. Unspent ITA dollars remain with Workforce Escarosa.

5. Withdrawal from more than two classes is prohibited, unless warranted by extenuating circumstances and pre-

approved by your WIA Career Advisor. WIA will pay tuition for a course only once. Should you decide to

withdraw, drop out of, or not complete a course, you must advise your WIA Career Advisor as far in advance as

possible and be prepared to accept full responsibility for tuition and other expenses related to retaking those

classes anytime thereafter.

6. Career Source ESCAROSA does not pay in advance for state board examinations, certifications, or licensing. If

any of these are required before you can work in a training occupational area, you must first successfully meet the

requirement and then provide a copy of the results (test scores, certificate or license) and a copy of your receipt

for payment to your WIA Career Advisor for reimbursement.

7. WIA may purchase training related items (i.e., tools, kits, supplies, uniforms) for use in the classroom. Items

purchased under WIA remain the property of Career Source ESCAROSA until you complete the training program

and obtain unsubsidized employment in the occupational area relating to your training program. If you do not

successfully complete the training, you agree to return those items to your WIA Career Advisor within 30

days from the date you drop out of or withdraw from training. Furthermore, you accept full responsibility

for replacing all broken, lost, or stolen items, and ---in the event that you fail to adhere to this portion of the

agreement -- understand that Workforce Escarosa may take any/all measures necessary to recover its

property.

8. WIA Career Advisors must pre-approve all training related purchases. Career Source ESCAROSA may

contribute a maximum of $1,500.00 toward training related items/materials that are documented by the

educational institution as required by all students enrolled in a specific training program. You are responsible for

any/all costs exceeding this amount.

9. Career Source ESCAROSA will discontinue funding of your training program if you do not meet attendance and

grade requirements; are placed on academic warning, probation or suspension by the training institution; and/or if

you fail to meet any/all of the requirements as outlined in this agreement.

10. If you are being served under Career Source ESCAROSA Dislocated Worker program and find it necessary to

accept temporary employment while you are participating in WIA activities, you must sign a "Dislocated

Worker Employment during WIA funded Training Agreement” form before you begin such employment. Also,

please note: If you are called back to work by the company/employer from which you were laid off, BY LAW,

you will no longer be eligible for WIA services.

11. All services to be provided by Career Source ESCAROSA must be approved in writing by Career Source

ESCAROSA staff prior to rendering of services. WIA services include any and all items required for training

and/or employment. Career Source ESCAROSA reserves the right to decide which items and services will be

supplied by WIA. Career Source ESCAROSA will not be responsible for payment of item/services rendered if

the item/services were not pre-approved in writing by the appropriate Career Source ESCAROSA staff and

documented to the vendor before the purchase/receipt of the items/services.

12. Continuation of WIA services in support of your training is not fully guaranteed. WIA support is contingent upon

U.S Department of Labor, and the Florida Agency for Workforce Innovation’s continued receipt of federal funds

and the allocation of those funds to Career Source ESCAROSA. Services are also contingent upon Career Source

ESCAROSA’s local policies/guidelines.

I, , acknowledge that I have read, fully understand, and completely accept the

conditions of this Occupational Skills Training Agreement.

_____________________

WIA Participants Signature Date

_____________________

Career Source ESCAROSA Career Advisor Signature Date

Revised: 4/27/15 (BT)

Institution:

Institution:

Address:

Address:

City:

State/Zip:

County:

City:

State/Zip:

County:

Graduated? Yes No If NO, highest grade completed:

Completed? Yes No If NO, highest grade completed:

Institution:

Institution:

Address:

Address:

City:

State/Zip:

County:

City:

State/Zip:

County:

No

Completed: Yes _____ No ______

If NO, number of training hours completed? _________

Training Program: ____________ Certificate/Licensing Area(s): ________________________

Verification of Educational Background

I,_______________, hereby affirm that to the best of my knowledge and belief, the following information regarding my educational background is true.

HIGHSCHOOL GED

VOCATIONAL/TECHNICAL COLLEGE

Completed: Yes _____ No ______

If NO, number of training hours completed? _________

Training Program: _______________________________

Certificate/Licensing Area(s): _____________________

COLLEGE OTHER:

Institution:

Institution:

Address:

Address:

City:

State/Zip:

County:

City:

State/Zip:

County:

Completed: Yes______ No _______ GPA: __________ If NO, number of hours completed? ___________________________ Major/Degree: ____________________________________________

Completed: Yes______ No _______ GPA: __________ If NO, number of hours completed? ___________________________

Major/Degree: ____________________________________________

I UNDERSTAND THAT THE ABOVE INFORMATION IS SUBJECT TO VERIFICATION. I AGREE THAT OUTSIDE SOURCES MAY BE

CONTACTED AND I GIVE MY PERMISSION FOR DISCLOSURE OF SUCH INFORMATION TO THE CAREERSOURCE ESCAROSA REGIONAL

WORKFORCE DEVELOPMENT BOARD, INC.

SIGNED: DATE: _______________________

Date: ____________

Workforce Investment Act (WIA)

VERIFICATION OF HOUSEHOLD SIZE The term “family” means two or more persons related by blood, marriage, or Decree of Court, who are living in a single residence, and included in on or more of the following categories:

a.) Husband, Wife and Dependent Children b.) A Parent or Guardian and Dependent Children c.) A Husband and Wife

Applicant Name: Social Security Number:

Address:

Street City State ZIP

Name of Family Member: Age: Relationship: Social Security Number:

1.) ______

2.) ______

3.) ______

4.) ______

5.) ______

6.) ______

7.) ______

8.) ______

9.) ______

10.) ______

CERTIFICATION STATEMENT:

Disclosure of your social security number and that of your family household is voluntary. It is requested however,

pursuant to section 119.071(5)(a). Florida Statutes for the administration of WIA programs, and will be used in assessing

and reporting program performance and accountability to the federal government.

Applicant/Head-of-Household Signature Date

Equal Opportunity Is the Law

(29 CFR 37.30)

It is against the law for this recipient of Federal financial assistance to discriminate on the following bases:

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 or her participation in any WIA Title I – financially assisted

program or activity.

The recipient 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 administration of, or in connection with, such a program or activity.

What to Do If You Believe You Have Experienced Discrimination

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:

The recipient’s Equal Opportunity Officer:

Mrs. Janay Sims

CareerSource Escarosa

3670-2A North L Street

Pensacola, Florida 32505

(850) 473-0939

Or the:

Director, Civil Rights Center (CRC)

U.S. Department of Labor

200 Constitution Avenue NW

Room N-4123

Washington, DC 20210

If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final

Action, or until 90 days have passed (whichever is sooner) before filing with the Civil Rights Center (see address

above).

If the recipient does not give you a 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 recipient 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 (in other works, within 120

days after the day on which you filed your complaint with the recipient).

If the recipient 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.

I hereby acknowledge that I have read and received a copy of the Equal Opportunity Is the Law Notice.

Signature Date

Revised 4/7/2015

Page 1

Grievance/Complaint Hearing/Appeal Hearing Procedures

Workforce Investment Act (WIA), Trade Adjustment Act (TAA), Welfare Transition (WT/TANF) and Wagner-Peyser (WP) program participants and other interested parties (e.g., Contractors, One-Stop partners, One-Stop operators, and employers) affected by decision or actions of the local workforce system have a right to file grievances/complaints with the local Regional Workforce Board. The grievance/complaint should be filed with CareerSource Escarosa, Inc., in accordance with the procedures listed below. In the event you submit a grievance/complaint not under the authority of CareerSource Escarosa, Inc., CareerSource Escarosa will notify you within five (5) working days from the receipt of the grievance/complaint of the relevant agency responsible for the grievance/complaint.

Sexual Harassment Policy CareerSource Escarosa Sexual Harassment Policy will be provided to you.

Criminal Fraud and Abuse The procedures for reporting such incidents and instructions for completing the incident reporting form can be found at the following web site: http://www2.myflorida.com/awilpdg/incidentreport/default.htm. The form should be completed and mailed to: USDOL Office of Inspector General, Office of Investigations, Room S5514, 200 Constitution Ave. NW, Washington, D.C. 20210 or to USDOL South East Regional Inspector General for investigations, Office of Investigations, Sam Nunn Atlanta Federal Center, 61 Forsyth Street, SW, Suite 6T1, Atlanta, GA 30303. Reports or complaints alleging fraud and abuse may also be reported through the USDOL Hotline at 1-800-347-3756.

Reporting Discrimination Complaints To receive forms and procedures for filing discrimination complaints, call AWI at (850) 488-722, ext. 1330, 1340, 1338 or visit the following website: http://www2.myflorida.com//awi/pdglcivilrights/forms.pdf. You may file a discrimination complaint directly with the CareerSource Escarosa EEO Officer, Ms. Janay Sims, at 3670-2A North L Street, Pensacola, FL 32505, Phone: (850) 473-0939. A WIA/TAA complaint file with the U.S. Department of Labor, Civil Rights Center Discrimination Complaints 200 Constitution Ave., NW, Room N-4123 Washington, D.C. 20210 and a copy mailed to AWI, Office for Civil Rights, Suite 150, Caldwell Building, East Madison Street, Tallahassee, FL 32399-4129; and with the EEOC Tampa Area Office 501 East Polk Street, l0th floor Tampa, FL 33602, Phone: (813) 228-2310 or TTY (813) 228-2003. A WT complaint file with U.S. Department of Health and Human Services Office of Civil Rights, Inspector General Sam Nunn, Atlanta Federal Center, 61 Forsyth Street, SW, Suite 3B70, Atlanta, GA 30303 and a copy mailed to AWI, Office for Civil Rights, Suite 150, Caldwell Building, 107 East Madison Street, Tallahassee, FL 32399-4129; and with the EEOC Tampa Area Office 501 East Polk Street 10th Floor, Tampa, FL 33602 (813) 228-2310 or TIY (813) 228-2003. You may file electronically at the following website address: civil.rights@awi.state.fl.us. A WP complaint may be filed directly with a local-office EO Officer or with the U.S. Department of Labor, Civil Rights Center Discrimination Complaints 200 Constitution Ave., NM, Room N-4123Washington, D.C. 20210. If the person filing the complaint is sight or speech impaired, they should call the Florida Relay System at 1-800-955-8771 (TDD) or 1-800-955-8770 for voice assistance.

Filing a Grievance/Complaint and request for Hearing/Appeal with Workforce Escarosa, Inc. A WIA/TAA/WTP individual or entity, adversely affected by a CareerSource Escarosa action, to include but not limited to: displacement of employee; denial or termination as a WIA training provider; denial of eligibility as a WIA OJT or customized training provider; participant sanctioned for using controlled substances; termination of program eligibility or sanctioning for non-compliance with work activities, may submit a Grievance/Complaint or hearing request. Submissions should be concise and clearly written or typed; state the facts, laws, procedures, etc. that the grievant/complainant believes to be relevant for review; and must include a legible address where official notices may be mailed to the grievant/complainant; include the words REQUEST FOR A HEARING at the top of the first page in capital letters; and specifically state the type of violation and nature of the action that is the subject of the grievance. The grievance shall be no longer than five pages (exhibits and attachments are not included in the five-page limit) and submitted to CareerSource Escarosa, Executive Director at: 3670-2A North L Street, Pensacola, FL 32505. If possible, CareerSource Escarosa will attempt to resolve the grievance/complaint informally. If the matter cannot be resolved informally, CareerSource Escarosa must establish a hearing date, complete the hearing and issue a decision within a 60=calendar day timeframe from the date the grievance/complaint was filed. When the matter is not resolved informally, you will be notified by certified mail return receipt at least 15 calendar days prior to the hearing. The written hearing notice will include: hearing procedures date, time, and place of the hearing; pertinent sections of the WIA, WT, and any federal regulations involved. Affected parties may be represented at the hearing by an attorney or other representative, and may present witnesses or documentary evidence at the hearing. The parties will receive a written decision of the hearing within 30 calendar days after the hearing by certified mail return receipt requested.

Page 2 – Grievance/Complaint Hearing/Appeal Procedures

Individuals alleging a labor standards violation may submit the grievance/complaint to binding arbitration procedure if the affected parties are covered by a collective bargaining agreement. WP participants file discrimination complaints against the Agency for Workforce Innovation (AWI) or its employees or complaints alleging discrimination by an employer. Special handling procedures are required for complaints filed by Migrant and Seasonal Farm Workers (MSFW). The RWB shall attempt to resolve the MSFW complaint. If the MSFW complaints cannot be resolved within five working days of receipt of complaint by the RWB, the complaint form and copies of all documents in the complaint file are forwarded to the Agency for Workforce Innovation, Monitor Advocate Office, Caldwell Building, 107 East Madison Street, Ste. 150, Tallahassee, FL 32399-4133. Attention: Senior Monitor Advocate. *Note: Individuals with a disability needing special accommodations shall call CareerSource Escarosa at (850) 607-8700, or fax at (850) 607-8852 at least five (5) working days prior to the hearing and state what special accommodation requirements are needed in order to participate in the hearing.

Right to Appeal: An individual, or entity, adversely affected by CareerSource Escarosa actions or decisions can file an appeal with the State WIA/TAA Administrative entity. An appeal may be made to the federal level (USDOL) if the state has not conducted a hearing a decision regarding the grievance/complaint within the mandated 60-calendar day timeframe, or if either party is dissatisfied with the state hearing decision. If the AWI Administrative Entity in conjunction with State Board staff determines that a grievance/complaint filed at the State level should have been decided at the local level, then the grievance/complaint may be remanded back to CareerSource Escarosa.

Filing a Grievance/Complaint and request for Hearing/Appeal at the State Level: Because of the many types of grievances/complaints and level of hearing/appeals allowed under WIA/TAA/WT regulations, AWI staff working in conjunction with the State Board staff will be responsible for reviewing and determining the appropriate processing of requests/appeals filed at the State level. The following procedures should be followed when filing a grievance/complaint and/or requesting a hearing/appeal regarding a CareerSource Escarosa decision. The request and/or grievance/complaint for a hearing appeal should be clearly identified at top of the first page, i.e., REQUEST FOR HEARING. The written hearing request should not exceed five pages (not including attachments) and should state the facts, procedures, etc. that the griever/complainant believes to be relevant for review and, is applicable, shall include any written decision made by CareerSource Escarosa and an address where official notices may be mailed to the grievant/complainant. The request shall be sent by certified mail return receipt to AWI, Office of General Counsel, Caldwell Building-Suite 150, 107 East Madison Street, Tallahassee, FL, 32399-4128. The grievant/complainant and CareerSource Escarosa will be contacted at least (5) five working days of receipt of the complaint to attempt an informal resolution. If informal methods do not resolve the issue, then a hearing will be scheduled. The complainant/grievant will be notified of the specific procedures for the hearing and will receive a decision within 60 calendar days from receipt. State and Federal Appeal Level Process: If the DEO has not reached a decision on the appeal of a local decision or the grievant disagrees with the decision, the grievance/complainant can file an appeal to USDOL no later than 60 calendar days of receipt of the decision being appealed. That request is submitted by certified mail, return receipt to Secretary USDOL, Attention: ASET, Washington, D.C. 20210. A copy of the appeal must be simultaneously provided to AWI (address above). Actions that may not be appealed to USDOL include: sanctions applied at the local level for using a controlled substance; sanction for non-compliance with work activities; or denial of eligibility as a WIA/TAA training provider. WP states that non-ES related complaints (employment, discrimination,

health and safety, etc.) must be forwarded as soon as possible after being received, to AWI, Office of General Counsel, Caldwell Building | Suite 150, 107 East Madison St, Tallahassee, FL, 32399-4128, or to the appropriate federal agency with a copy of the complaint sent to AWI Office of General Counsel. If the WP complaint is not resolved within 15 working days, then the complaint and associated file documents are forwarded to the AWI, Office of One-Stop and Program Support, Caldwell Building | Suite 105, 107 East Madison St, Tallahassee FL 32399-4133, Attention: ES Complaint Coordinator.

I certify that I have read and understand my rights and responsibilities as enumerated above.

Participant/Service Provider/ Employee/Employer or Other Signature & Date

As a representative of CareerSource Escarosa, I verify that the above-signed individual has read the Grievance Hearing/Appeal Procedures and has indicated an understanding of it.

CareerSource Escarosa Representative Signature & Date

MONTHLY EXPENSES: $ AMOUNT:

Rent/Mortgage PaymentMortgage InsuranceElectricity Bill (Average)Gas (Average)Water/Sewage (Average)Garbage CollectionTelephone (Average)Cellular Telephone (Average)Cable Bill (Average)Vehicle Payment(s)Vehicle InsuranceLife InsuranceCredit Card PaymentsLoans (Other than Mortgage)Child Support/AlimonyMedical Expenses (hospital bills/prescriptions)Child Care/Day CareFood/Household SuppliesEntertainmentGasoline (Automobile)Other Personal/Family ExpensesSpecify with subtotals:Other Expenses (Specify):

TOTAL EXPENSES:

FINANCIAL STATEMENT

Participant Name: ______________________________Address: ____________________________________________________________________________________Telephone: ___________________________________

MONTHLY INCOME: $ AMOUNT:

Employment earningsUnemployment CompensationWorker's CompensationSocial SecurityPell Grant/Other GrantsSpecify with subtotals:

Child Support/AlimonyPublic Assistance (e.g., TANF)Food StampsOther (Specify):

Total Income:

COMPUTATION: $ AMOUNT:

Total IncomeTotal ExpensesTotal Remainder

Applicant Comment:

Staff Comment/Assessment:

Applicant Signature Date

Staff Signature Date

Acknowledgements:

I have worked with my WIA Career Advisor to identify my employment goals and to plan activities to help me re-enter the workforce. I agree to complete all activities and responsibilities outlined in my employment goal. If I have a problem with my activity, it is my responsibility to notify my WIA Career Advisor within 3-5 business days.

By signing below, I acknowledge that my opportunities and obligations as a participant of the WIA Program have been explained to me.

Participant: _____________________________

Signature: ______________________________ Date: _________________

As the WIA Career Advisor, I will assist the WIA Participant identified above in planning the needed activities (to the extent that funds and services are available). I will monitor progress and attendance in assigned activities, will provide regular feedback, and provide employment counseling when necessary.

WIA Career Advisor: ____________________________ Phone Number: __________________

Signature: ____________________________________ Date: ________________________

**THIS DOCUMENT CONTAINS CONFIDENTIAL INFORMATION AND IS PROTECTED BY LAW. IT IS INTENDED FOR USE BY AUTHORIZED USERS ONLY AND WILL BE KEPT AS PART OF PARTICIPANT’S RECORDS. IT IS NOT FOR PUBLIC DISSEMINATION**

APPOINTMENT FOR WIA ELIGIBILITY INTERVIEW

Customer Name: _________________________________________

Staff Contact: ____________________________________________

Please be sure to bring all items marked with a check below to your scheduled appointment.

SOCIAL SECURITY NUMBER: Social Security Card Social Security Benefits DD214 W2 Form IRS Form Social Security Letter Public Assistance Doc.

MAILING ADDRESS: Driver’s License State ID Agency Document Landlord Statement Rent Receipt Utility Bill Postmarked Mail

CITIZENSHIP/ALIEN STATUS: Birth Certificate Passport Public Assistance Record INS Document

BIRTHDATE/AGE: Birth Certificate Driver’s License Government ID Card

VETERAN STATUS: DD-214, Page 4 FAMILY INCOME: LES (Military) Paystubs Unemployment Comp. P.A. Document DISABILITY: Doctor’s Statement VA Letter Agency Letter W.C. Statement

PUBLIC ASSISTANCE: DCF Letter/Notice TANF Statement SNAP Letter (formerly known as Food Stamps) HOMELESS: Shelter Statement Agency Statement Temporary Residence Document

WIA INDIVIDUAL RESPONSIBILITY PLAN

Name: _______________________ SSN: ____________________ Date: _____________

WIA Career Advisor: ________________________________

Do you have a High School Diploma?

YES NO

Have you completed any college?

YES NO

Do you have any vocational certifications?

YES NO

What is your employment plan or goal?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

What are you interested in pursuing this occupational employment?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Did you use an assessment tool in reaching this decision? ___________________________________________

Do you think an assessment tool would be beneficial to you?

YES NO

Which of your current skills and abilities can be transferred to your employment goal(s)?

__________________________________________________________________________________________

__________________________________________________________________________________________

What are your strengths? _____________________________________________________________________

__________________________________________________________________________________________

Page 1

What are you weaknesses? __________________________________________________________________

________________________________________________________________________________________

If you employment goal requires additional skills, knowledge and abilities; how to do you plan to obtain them?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

While preparing for your employment goal(s), will you need work? __________________

If yes, what type of work?

Full-time Part-time

If no, what is the duration of time you anticipate not working? ______________________________________

What is the minimum salary you will accept? ____________________________________________________

Have you researched the salary range of your employment goal in the local economy? ___________________

_________________________________________________________________________________________

Do you plan to relocate?

YES *Where? ________________________________________

NO

If necessary, would you relocate to obtain employment?

YES

NO

How far are you willing to commute from your current location? __________________________

Do you have a valid Driver’s License issued by the State of Florida?

YES

NO

If NO, is this preventing you from successfully obtaining employment?

YES

NO

Page 2

Do you currently have reliable transportation?

YES

NO

Do you need assistance creating or updating your resume?

YES

NO

Do you have a criminal record?

YES

NO

If YES, please explain the nature of your crime: ___________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Are you interested in the Federal Bonding Program?

YES

NO

Page 3

Steps needed to meet my employment goal. (Read & Initial Each One)

1. Submit monthly attendance forms Initial: _____

2. Maintain a minimum overall 2.0 GPA Initial: _____

3. Maintain monthly contact with Career Advisor,

including changes in phone, email, and address Initial: _____

4. Complete training program and provide

Career Advisor with proof of completion

(e.g., Diploma, certificate, transcript) Initial: _____

5. Inform Career Advisor when employed,

including start date, pay rate, and

point of contact for employment verification. Initial: _____

6. Cooperate with Career Advisor in completing all

required quarterly follow-ups after employment. Initial: _____

WORKFORCE INVESTMENT ACT

School Information Release Authorization

By signing this form, I ______________________ authorize the educational institution identified below to

release any and all information pertaining to my education records to a representative of CareerSource Escarosa

upon request.

Such information includes:

a.) Class attendance records

b.) Class grade(s)

c.) Financial reports

d.) PELL Grant Needs-Analysis Reports

e.) Student Aid reports

f.) Other educational information as required

This authorization remains in effect for the extent of my participation in WIA sponsored training.

EDUCATIONAL INSTITUION: ___________________________________

MY TRAINING PROGRAM: _____________________________________

DATES OF ENROLLMENT: ______________________________________

STUDENT NAME: ____________________________________________

LAST 4 DIGITS OF SSN: ___________________

WIA Participant Signature___________________________________ Date: __________________

WORKFORCE INVESTMENT ACT (WIA)

I, __________________, acknowledge that by not submitting the classroom attendance

forms required (monthly), that financial support for my training program may be

withdrawn by WIA.

Participant Signature: ____________________________ Date: ________________

WORKFORCE INVESTMENT ACT (WIA)

In order to be eligible for services under the

WORKFORCE INVESTMENT ACT (WIA):

You must apply for a *PELL Grant each year.

*Exceptions: Invidisuals with a Bachelor’s Degree and/or individiuals enrolled in a training program that is less than nine (9) months.

By signing below you are indicating that you have received information and:

1.) You have applied for a PELL Grant

OR

2.) Are in the process of applying for the PELL Grant.

Please Print Name:

Signature: Date:

WIA EMPLOYMENT DURING TRAINING AGREEMENT

Due to financial hardship, I have found it necessary to accept temporary employment during the period

of time that I am attending WIA sponsored Occupation Skills Training.

Upon completion of my training, I fully understand that I am required to seek and obtain employment

within the area trained.

I agree that this temporary employment will not interfere with WIA sponsored training.

Customer Signature: _______________________________ Date: _________________

Career Advisor: ___________________________________ Date: __________________