Online Job-Seeker Referral Form

This is for partner agencies OR Job Seekers making a referral to the Workforce Center. Referrals must be submitted 14 days prior to training start date. Please allow two business days for contact by a Workforce Professional.

Referring Agency

Referring Staff Name

Referring Staff Phone

Referring Staff E-mail

Customer Name*

Date of Birth

Open the calendar popup.

Last Four of SSN

Best time to contact*

Phone*

E-mail*

Preferred Method of Contact*

Participant ID (Workforce Center use only)

Previous or Current Employer*

Last Date of Employment

Open the calendar popup.

Requesting training assistance:

Yes

School Preference and Program

If referral is ages 16-24, check each applicable box

Program

Customer Referred To

Reason for Referral/Additional Comments

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Attachment 6

UserEmailAddress*

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Receiving SNAP	Unemployed
Receiving TANF	Laid off
Military Veteran	Receiving Unemployment Benefits
Eligible Spouse	Has a Misdemeanor or Felony
Employed	Language Barrier

Homeless	English Language Learner
Runaway	Pregnant or Parenting
Disabled	Currently in or aged out of foster care