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CalJOBS Registration - Addendum
Customer Information
Please print your name:
What are the last 4 digits of your SSN:
Do you consider yourself to have a disability? o Yes o No
If yes, is your disability (impairment): o Physical o Mental o Both o Do not wish to disclose
Employment Information
Employment Status: o Employed o Employed, but received notice of termination of employment/military separation
o Not Employed
If employed, Individual is Under-Employed? o Yes o No
Unemployment Eligibility Status: o Neither Claimant nor Exhaustee o Claimant o Exhaustee
If not working, the number of weeks unemployed: ______
o Category 1 – Terminated or laid off, or has received notice of termination or layoff,andiseligible for or has exhausted entitlements to Unemployment Compensation (UC), andis unlikely to return to previous industry or occupation.
o Category 2 – Terminated or laid off, or has received notice of termination or layoff,andhas been employed for sufficient duration (based on state policy) to demonstrate workforce attachment, butis not eligible for UC due to insufficient earnings,orthe employer is not covered under the state UC law, andis unlikely to return to previous industry or occupation covered under state compensation law and is unlikely to return to previous industry or occupation.
o Category 3 – Individual is terminated or laid off, or has received notice of termination or layoff, from employment as a result of thePermanent closure oforsubstantial layoffat a plant, facility or enterprise.
o Category 4 – Individual isemployedat a facility at which the employer has made ageneral announcement that the facility will close. Enter the date the facility will close (if known) in the Projected Layoff Date below.
o Category 5 – Individual waspreviously self-employed(including farmers, ranchers and fishermen), butis unemployeddue to generaleconomic conditionsin the community of residence or because ofnatural disaster. Record the last date of self-employment in the Actual Layoff Date.
o Category 6 – Displaced Homemaker: An individual who has been providingunpaid services to family membersin the homeandhas been dependent on the income of another family member but isno longer supported by that income;oris thedependent spouseof a member of the Armed Forces on active duty and whosefamily income is significantly reducedbecause of a deployment, or a call or order to active duty, or a permanent change of station, or the service-connected death or disability of the member;andisunemployedorunderemployedandis experiencing difficulty in obtaining or upgrading employment.
o Category 7 – Thespouse of a member of the Armed Forceson active duty,andwho has experienced aloss of employment as a direct result of relocation to accommodate a permanent change in duty stationof such member.
o Category 8 – Thespouse of a member of the Armed Forceson active duty and who isunemployedor underemployedandis experiencing difficulty in obtaining or upgrading employment.
o Category 12 – Dislocated Worker Grant (DWG) Eligibility: Individual does not meet criteria outlined for Dislocated Workers in categories 1-8 above, but is an individual that meets DWG eligibility outlined under WIOA Title ID National programs, Sec. 170 National dislocated worker grants, relating to Sec 170(b)(1)(A) workers affected by major economic dislocations OR SEC 170(b)(1)(B) workers affected by an emergency or major disaster.
If Category 12, answer the following questions:
o Is unemployed due to general economic conditions in the community lived or worked in, or related to military installation realignment.
o Is unemployed as a result of an emergency or natural disaster in the community lived or worked in.
o Considered long term unemployed, as defined by the state in the NDWG grant.
o None of the above. Individual does not meet the definition of Dislocated Worker.
Actual/Projected Date of Layoff or Closure: ______
Dislocation Employer:
Street Address:
City: / ZIP:
Occupation:
Dislocation Hourly Wage: ______
Educational Information
Highest School Grade Completed: o High School Diploma o High School Equivalency Diploma (GED) o Certificate of Attendance/Completion (Disabled Individuals) o If less than High School graduate, number of grades completed: ______
o Vocational School Certificate o College or a Technical or Vocational School, Years completed: ______
o AA o BA/BS o Master’s Degree o Doctorate Degree
School Status: o In-School, Secondary School or less o In-School, Alternative School o In-School, post-Secondary School o Not attending school, or Secondary school Dropout o Not attending school, or Secondary School Graduate or has a recognized equivalent o Not attending school; within age of compulsory school attendance
Education Partner Services
Receiving services from Adult Education (WIOA Title II): o Yes o No o Did not self-identify
Receiving services from YouthBuild: o Yes o No o Did not self-identify If yes, Grant # ______(If unknown, enter all 9s)
Receiving services from Job Corps: o Yes o No o Did not self-identify
Receiving services from Vocational Education (Carl Perkins): o Yes o No o Did not self-identify
Public Assistance (currently receiving or have received in the past 6 months)
Receiving CalWORKS (TANF): o Yes o No If yes, o Applicant o Family Member o Not Applicable/Unknown
Supplemental Security Income (SSI): o Yes o No If yes, o Applicant o Family Member o Not Applicable/Unknown
General Assistance: o Yes o No / CalFRESH (SNAP/Food Stamps): o Yes o No o Unknown
Refugee Cash Assistance (RCA): o Yes o No / Social Security Disability Insurance (SSDI): o Yes o No
Currently receiving services under SNAP Employment & Training Program: o Yes o No o Unknown
Pell Grant: o Yes o No / Ticket to Work Holder issued by the Social Security Administration: o Yes o No
Individual Barriers
English language learner: o Yes o No / Basic skills deficient/Low Levels of Literacy: o Yes o No
Homeless: o Yes o No / Ex-Offender: o Yes o No
Barriers to Employment
Displaced Homemaker: o Yes o No / Within 2 years of exhausting TANF lifetime eligibility: o Yes o No
Are you a single parent (including single pregnant women)? o Yes o No / Cultural Barriers: o Yes o No
Eligible Migrant Season Farmworker (as defined WIOA Sec 167 i): o Yes o No
Meets Governor’s special barriers to employment: o Yes n No
Family Income
How many members are in your family? ______/ What is your annual (yearly) family income? ______
Barriers
Gang Status: Gang Member o Yes o No Gang Involved o Yes o No At Risk Gang Involvement o Yes o No
Youth of Incarcerated Parent: o Yes o No / Substance Abuse: o Yes o No
By signing below, I acknowledge that I have received copies of: 1) Code of Conduct; 2) Grievance, Non-discrimination and Equal Opportunity complaint Procedures; and 3) Release of Information. In addition, my signature below indicates that I have been informed of and understand the information contained on this form. I certify under penalty of perjury that all of the above information is true and complete. I agree that any information I have supplied is subject to verification. I understand that falsification of any item is grounds for termination from the Workforce Innovation and Opportunity Act (WIOA) program and may result in action to recover any monies paid to me while participating.
Please Print Name:
Signature: / Date:
Staff Use Only
Signature of Interviewer: / Date:

JH 3/6/2017