DENVER – PREP INTAKE FORM - Colorado
Veterans Workforce Investment Program (VWIP) Pre-Enrollment Application
Date:
First Name MI Last Name
Street Address
City County State Zip Code
Phone #: ( ) - E-mail:________________________________________
SSN#: - - DOC #:
Date of Birth: / / Age:
Gender: χ Female χ Male
Are you registered with Selective Service? χ Yes χ No
Ethnicity: Are you Hispanic? χ Yes χ No
Race: (check all that apply)
χ American Indian / Alaska Native χ Hawaiian Native or Other Pacific Islander
χ Asian χ White / Caucasian
χ Black / African American χ Other
Are you Currently Homeless? χ Yes χ No If yes how long? ____________________________
Are you currently enrolled in HVRP? χ Yes χ No
Have you ever been to a Veterans Stand-down? χ Yes χ No
Are you Service Connected Disabled? χ Yes χ No If yes, at what percent? _________%
Do you currently have a claim open or pending with the VA? χ Yes χ No
If yes what is the status? ________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
MILITARY SERVICE:
χ 0-3 Years Ago χ 4-7 Years Ago χ 8-11 Years Ago
χ 12-15 Years Ago χ 16-19 Years ago χ 20+ Years Ago
Do you have a campaign badge? χ Yes χ No
If yes, is it a campaign badge for service in a recent war? χ Iraq χ Afghanistan χ Other _____________
BENEFITS INFORMATION / OTHER:
Do you receive public assistance at enrollment? χ Yes χ No
χ SSI / SSDI / SSA χ TANF χ Food Stamps χ Unemployment Insurance
χ Div. of AIDS Services Income Support χ Medicaid χ Medicare
χ Private Health Insurance through work or family member χ Other
If you receive SSI what is your disability?
What amount do you receive each month? $
Do you have any child support obligations? χ Yes χ No
If YES, Number of Children: Amount: $
FINANCIAL STATUS:
Please indicate the level of your last full yearly income:
χ Below $8,000 χ Between $8,000 & $18,000 χ Between $18,000 & $28,000
χ Between $28,000 & $35,000 χ Above $35,000
Including yourself how many people are currently supported by your yearly family income?
Are you required to pay restitution? χ Yes χ No If YES, how much per month? $
IDENTIFICATION/TRANSPORTATION: (Check all that you DO have in your possession)
χ Current Driver’s License χ Current State ID χ Birth Certificate χ DOC ID
χ Social Security Card χ Green Card χ DD214 (Veterans) χ Passport
Can you show us (do you have possession of) any of these documents? χ Yes χ No
What do you need to obtain a Driver’s License?
(Revoked until , SR22, old fines, drug/alcohol classes, child support, money for test, other)
χ Bus transportation χ Own car/truck χ Bicycle
SPECIAL SOCIAL SERVICE NEEDS: Note: VWIP may not provide the following services, but may help locate resources to meet your needs.
χ Bus Tokens χ Housing χ Child Care χ Medical appointments/testing
χ Bicycle χ Emotional counseling χ Eyeglasses χ Drug/Alcohol counseling
χ Tools χ Food Voucher χ Work Clothes χ Community Voice Mail
χ Federal Bonding χ Hard Skills Training χ Interview Clothing
χ Other: ______________________________________________________
Other Contact Information:
__________________________________________________________ ___________________________________
Contact Name Relation to You
Organization / Employer / Hang Out (if applicable)
Street Address
City County State Zip Code
Phone: ( ) Other Phone: ( )
What times are you there?
Your Comments and Concerns:
................
................
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