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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