NAME: *
ADDRESS:
PHONE: *
EMAIL: *

Please check all that apply

 Veteran
 Lack of GED or High School Diploma
 Eligible to receive or are receiving unemployment benefits
 Receiving TANF
 Exhausted unemployment benefits
 Receiving food stamps
 Laid off from a permanent full-time position
 Homeless
 Unemployed for more than 27 weeks
 Seasonal farm worker
 Unemployed for more than 12 months
 Displaced Homemaker
 Limited English Proficiency
 Non-custodial parent
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