Colorado Employment First Enrollment Form

COLORADOEMPLOYMENTFIRSTENROLLMENTFORM (HYBRID-VOLUNTARY)

Today’sDate: / FATech: / Unit: / Office:
Participantis:UnderSanctionExpedited/ComplyABAWD Non-ABAWDVolunteer
Name: / DOB:
Address: / CBMSCase#:1B
City/State/Zip:CO / SSN:
Phone Number: / Email Address:
CurrentlyWorking Yes/No / DateLastWorked: / HighestGradeCompleted:

You arescheduled forOrientationwith theEmploymentFirst(EF)Program on:

Date: ______, at ______(am / pm) Allow at least ___ hours for orientation.

Location/Contact Info. / Address:
City/State/Zip:
EF Phone #: / EF Fax #:
EF Email:

IunderstandthatIamNOTrequiredto attendany scheduledmeetings,includingmyorientationmeetingasspecifiedabove. If I choose to attendorientation,Iwillreceivefurtherinformationabout resources, services, andsupports.MyongoingparticipationisNOTrequiredinordertobeeligiblefor foodassistancebut it is encouraged. I also understand that if I am receiving Food Assistance and am between ages 18-49, with no children in the home under the age of 18 and do not qualify for any federal exemptions, I must meet a monthly work requirement to keep my food assistance benefits for longer than three months in any 36 month period. You can learn more by attending your orientation.

IunderstandthatallowancesorreimbursementsforcoststhatarereasonablynecessaryanddirectlyrelatedtomyparticipationmaybeavailableifIdiscussthiswithEmployment First beforeincurringanyexpense.Contactyour countiesColoradoEmploymentFirstUnitforadditionalinformation. Ifyouhavefoundemployment,protectyourfuturebenefitsbynotifyingtheEFUnit.Completetheinformationbelowandreturnthisformtotheaddressshownabove, orcallorfax the informationtothenumberslistedabove.

Employer: / ContactName:
Phone#:
Position: / StartDate: / HourlyWage: / HoursperWeek:
EmploymentType(Circle): / Permanent(over90days) / Temporary(30-90days) / Temporary(under30days)
Employer Signature:

Iunderstandthatbysigningbelow,Iauthorizeanyperson,agency,oremployertosupplyinformationaboutmyemploymentorprogramparticipationtotheEmploymentFirstProgram.IfIamanotherhouseholdmembersigningfortheparticipant,Iagreetoinform thepersonbeingreferredoftheirappointmentdate,timeandlocations listed above and understandthatfailuretoreportmayresultinthereductionorlossoffoodassistancebenefitsformyhousehold.

ClientSignature: / PhoneNumber:
Comments:

F-102(R8/2017)Original–EmploymentFirst Yellow – FoodAssistanceCaseFilePink– Participant 615-82-22-1117