Workforce Investment Act (WIA)
Belmont County Department of Job and Family Services

Mailing Address:
310 Fox-Shannon Place, St. Clairsville, OH 43950

WIA Office Location:
302 Walnut St., Martins Ferry, OH 43935
740.633.5627 or Toll-Free 1.877.516.5627
Preliminary Application: Request for Training Services


Name


Address


City


State


Zip


Phone


E-mail


Birth Date


Race/Ethnic Background


Gender:    

Veteran:    

Please provide the following information regarding your request for training assistance.

Training Facility Name


Training Program


Start Date


Type of assistance needed (e.g. tuition, books, tools, uniform, gas stipend, daycare, etc.)


If you are currently attending a training facility, list GPA


Financial Aid

Receiving




Family Size


Estimate of Family Gross Income for Last 6 Months


Please check if you receive any of the following or if they apply







Have you been laid-off or terminated from your job?
  

If yes, list the name of the employer and the termination date
Employer: Termination Date:

Are you currently receiving or exausted unemployment compensation?
  

Are you an individual who has been providing unpaid services to family members in the home and has been supported by the income of another family member, such as a spouse, but has lost that income due to death, divorce, or other reasons?
  

Are you unemployed, underemployed or having difficulty finding employment?
  

I authorize the exchange of informationbetween the Belmont County Department of Job and Family Services and the training facility listed above as it pertains to this application:   

This agency DOES NOT unfairly exclude individuals from oppertunities or make decisions based upon Race, Color, Religion, National Origin, Political Affiliation, Age, or Disability.
The completion of this application DOES NOT create entitlement to services authorized under the Workforce Investment Act.