Pre Application

Please take a moment to complete the following information. This form can be used to register with Gallia County, Jackson County & Lawrence County Centers.  The information is used to determine how our staff can assist you and determine funding sources that can best assist you. All Information is kept CONFIDENTIAL and is shared with partners ONLY.
By completing and sending this application, I understand and agree that the staff of the  Resource Centers and all partners herein may exchange and disclose information on me in order to make determinations of my eligibility for benefits and/or services provided by programs under partner agencies. I further agree that information regarding any employment obtained may be verified by my employer.

First Name Middle Initial
Last Name Social Security Number
Street Address APT #
City, State Zip Code
County of Residence US Citizen Yes No
Date of Birth Telephone Number
Race Black Hispanic Native American White Asian Other
Career Interest Wages
Grade School 1 - 8 High School 9 - 12 Post Secondary Education 13 - 19
Education Level 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Labor Force Status
Education: Choose the highest degree that you received
If you have degree and/or certificate please describe majors, minors and nature of certificates and their dates.
Veteran Status Yes No If Yes, Please complete Veteran Section Gender Male Female
Individual with disability Yes No If Yes, Type of disability


I would like assistance with the following services. Note: To choose more than one you must hold down the CTRL button while clicking.


Current Source of Income
(Check all that apply and Approximate $ over the last 6 months)


Employment Unemployment Comp.
Social Security VA Payment
Self-Employed Retirement
Child Support Alimony
Workers Compensation Public Assistance
Other
If you receive unemployment, when did the benefit start? Are the benefits exhausted Yes No
Are you a convicted felon? Yes No Do you have a valid drivers license? Yes No
Ohio Counties that you would consider employment. Please List. Other states that you would consider employment. Please List.


What length of time are you interested in working: Are you interested in part time or full time Employment:
What is your shift preference:

Do you live in the Huntington-Ironton Empowerment Zone Area:
Empowerment Zone Area is Railroad St. to Spruce St. and River to Hill (Map is available) 		Yes No


If not a veteran or you have completed the veteran section click here to submit registration.




VETERAN SECTION
PART A Have you ever served in the military or has your spouse ever served in the military? Yes No
PART B 1. I served on active duty for a period of over 180 days and was discharged or released therefrom with other than a dishonorable dicharge. Yes No
  2. I served as a member of a reserve component or national guard unit ordered to active duty for a (length of) time during a period of war and was discharged or released from such duty with other than a dishonorable discharge. Yes No
  3. I served as a vietnam Era Veteran some time between August 5, 1964 and May 7, 1975. Yes No
  4. I served before August 5, 1964 or after May 7, 1975. Yes No
  5. I served during the period beginning February 28, 1961 thru August 4, 1964 in the Republic of Vietnam, Laos, Cambodia, Thailand or the adjacent waters. Yes No
  6. I was discharged or released from active duty due to a disability incurred in or aggravatedby military service. Yes No
  7. I have been rated at 30% or more by the VA for a service connected disability. Yes No
  8. I have a service connected disability rated by the VA at less than 30%. Yes No
  9. I was seperated from the military within the past 48 months. Yes No
PART C If you are not a veteran, are you entitled to service because you are the spouse of any member of the armed service who:  
  1. Died as the result of a service connected disability? Yes No
  2. Has a permanent, total disability resulting from a service connected disability? Yes No
  3. Died while that disability was in existance? Yes No
  4. Is listed and has been listed as missing in action for more than 90 days? Yes No
  5. Is listed and has been listed as captured in the line of duty by hostile forces for more than 90 days? Yes No
  6. Is os has been forcibly detained or interned in the line of duty by a foreign government or power for more than 90 days? Yes No
  7. Does not fit any of these descriptions? Yes No
PART D 1. What date did you enter active military service?   1. What date were you discharged from active military service?



To continue back on the first page to complete Pre Application Click Here