ARC Application Form

CONTACT INFORMATION

First Name

Middle Name Initial:

Last Name

Street

City

Zipcode

County:

State

Country

Are you a current client or have you received assistance from ANEW in the past 2 years? YesNo	Availability: 8 am - 12:00 pm12:00 pm - 5:00 pmAnytime
Mobile Phone Number:	SMS Opt In I agree to receive text messagesI don't agree to receive text messagesmobile messaging rates may apply
Email Address	Indicate preferred contact method: CellTextEmail

ARC Eligibility

ARC Eligibility:

Are you enrolled in a pre-apprenticeship program?

YesNo

Please indicate which pre-apprenticeship program are you enrolled in:

ANEW-TRP	PACE
PACT	YouthBuild
TRAC	CTAP
TERO	Job Corps
Other

Other (enrolled pre-apprenticeship program):

Are you already an apprentice?

YesNo

What is your Apprentice Id?

What year apprentice are you?

What trade are you in?

What union?

Did you complete a pre-apprenticeship program before entering apprenticeship?

YesNo

Please indicate which pre-apprenticeship program did you complete:

ANEW-TRP	PACE
PACT	YouthBuild
TRAC	CTAP
TERO	Job Corps
Other

Other (name of completed pre-apprenticeship program):

How do you best describe yourself?

American Indian/Alaska Native	Asian
Black or African American	Native Hawaiian or Pacific Islander
White	Hispanic, Latino, Spanish origin
More than one race	Prefer not to disclose

Are you currently working?

YesNo

When did you last work?

Are you married?

YesNo

Do you have dependent children?

YesNo

How many dependent children do you support?

Please indicate their name and ages separated by comma:

Have you worked anywhere in the past 30 days?

YesNo

Has your spouse worked anywhere in the past 30 days?

YesNo

What was/is your hourly wage?

Enter only the number not the dollar sign

What was/is their hourly wage?

Enter only the number not the dollar sign

Are you receiving unemployment, or have you applied?

YesNo

How much unemployment do you receive each week?

Enter only the number not the dollar sign

Is your spouse receiving unemployment, or have they applied?

YesNo

How much unemployment does your spouse receive each week?

Enter only the number not the dollar sign

Are you receiving Basic Food assistance, or have you applied?

YesNo

Engagement ID

Contact ID:

Page 2

OUTREACH & RECRUITMENT INFORMATION

How did you hear about ANEW?

ReferralFriend/FamilyPre-Apprenticeship programApprenticeship programUnionSocial mediaWorkSourceCraigslistPort jobsDOCEvent

Referral's Name:

Referral's Email:

Social media (indicate):

Event (indicate name of the event):

EMPLOYMENT HISTORY

What is your current employment status?

Employed - full-timeEmployed - part-timeEmployed - seasonalCurrently on unemploymentNot employed - looking for workOther

Other:

Current or most recent employer:

Job title:

City:

State:

Starting Hourly Wage:

Enter only the number not the dollar sign

Hours worked per week:

Ending Hourly Wage:

Enter only the number not the dollar sign

Start date:

End Date:

Reason for leaving:

EDUCATION INFORMATION

What is your current education status?

Currently attending HS or GED program	9th-12th grade, no diploma or GED
HS Diploma	GED Certificate
Some College	Associate Degree
Technical or Vocational Certificate	Bachelor's Degree
Master's or Doctoral degree

High School Name:

City (where High School is located):

High School Graduation Date:

GED Institution Name:

GED Completion Date:

Have you completed FAFSA/WASFA?

YesNo

SELF IDENTIFICATION INFORMATION

Date of birth:

What is your gender?

Male	Female	Transgender
Non-binary	Prefer not to disclose	Other

Other (gender):

Pronouns:

How do you identify?

Heterosexual (Straight)	Gay
Lesbian	Bisexual
Prefer not to disclose	Other

Other (sexuality):

What is your immigration status?

CitizenLegal ResidentImmigrantRefugee

What is the primary language spoken in the home, if other than English?

Amharic	Arabic
Chinese	Korean
Not applicable	Other
Punjabi	Russian
Somali	Spanish
Tagalog	Ukranian
Vietnamese

Other (language):

Will you need translation services?

YesNo

Do you have a disability or require acoomodation?

YesNoPrefer not to disclose

Are you a veteran?

YesNoSpouse of eligible veteran

What is your current living situation?

Rent house or apartment	Own residence
Transitional/temporary housing	Couch surfing
Live in public housing community or shelter	Homeless
Work release

Are you currently or have you ever been in foster care?

Yes, before the age of 13Yes, after the age of 13NoI do not know

Have you experienced homelessness at any time within the last year, including currently? (more than one night staying at a hotel, motel, staying at a shelter or temporary housing program, couch surfing, sleeping in a car, a park, campsite or on the street, doubled up with another family due to hardship, or in a residence with inadequate facilities (i.e. no heat, water, electricity):

YesNo

Are you currently or have you in the last 12 months received mental healthcare?

YesNoPrefer not to disclose

ADDITIONAL QUESTIONS

*These questions are intended to enhance our ability to better serve you, with no intention of restricting your access to our services.

Can you speak English?

YesNo

Can you read and write in English?

YesNo

Do you have a Driver's License?

YesNo

What is your Driver's License status?

ValidSuspendedNever licensed

Provide your Driver License's number:

Driver's License State:

If your Driver License is suspended, please explain:

Please check all of the types of transportation you have access to:

I own a reliable vehicleI can borrow a reliable vehicleA dependable person has agreed to drive meCity bus/public transportationPay for rides/cab, Uber, etcNone/no access to transportation

What is your household size (including yourself)?

What is your annual household income (including anyone in the home)?

0 - $25,000$25,000 - $75,000$75,000 - $100,000$100,000 and above

What is your current household type?

Single adult	Single minor
Couple, no children	One parent family
Two parent family	Foster family

Are you currently receiving any of the following services? (Please check all that apply)

SNAP/food stampsUnemploymentTANF/WorkFirstSSI/SSDIReceive government assistance for housingOther support servicesI DO NOT receive any of the services above

Please name organizations that you receive support services from:

COURT INVOLVEMENT

Please note we ask these questions to better assist you with placement into employment.

Have you ever been justice involved? (juvenile or adult)

YesNo

If yes, please select from below:

Juvenile justice involvedMisdemeanor onlyMisdemeanor and felonyFelony only

Do you have any pending court dates for any matters?

YesNo

List any pending court dates for any matters:

Are you currently on probation or in Work Release?

YesNo

Probation Officer/CO Name:

Probation Officer/CO Phone:

Probation Duration (till when?):

County (probation):

Do you have check in requirements with your PO/CO?

YesNo

If yes, how often?

INFORMATION VERIFICATION STATEMENT:

Please read the statements below and input your initials.

I certify that the information provided is true to best of my knowledge. I am also aware that the information I have provided is subject to review and verification by ANEW staff, and I may have to provide documentation to support the information provided.

I allow release of this information for verification purposes and understand that it will be used to determine eligibility of services. I understand that receiving services is subject to availability of funding and that training and/or services are not guaranteed to me.

I indicate my willingness to be screened through Washington State Connections and allow the release of this information to ANEW staff for program monitoring, verification, additional data collection, and evaluation purposes.

My personal information will not be provided to any outside person or agency except where needed to determine eligibility for related programs or grant reporting purposes. Information provided on this form will not affect any benefits I am already receiving from other agencies.

NON-DISCRIMINATION POLICY:
ANEW follows the equal opportunity employment and training policy and does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, physical or mental ability, veteran status, military obligations, background, or marital status.

Signature of Applicant:

Date:

By digitally writing in my name, I agree to have it act as my signature.