WERC Enrollment/Intake Application
Privacy Policy: We will not lease, sell or distribute your personal information to any third parties, unless we have your permission. Your personal information will be used to determine eligibility for our program.
Email address *
Application Date *
Name *
Date of Birth *
Address include Street, City, State, and Zip code *
County of Residence *
Phone Number *
Race / Ethnicity *
Marital Status *
Number of years married prior to divorce, separation or widowed or if single never married what is the age of your oldest child. (Please put N/A if non-applicable) *
Number of Dependents (Please put 0 if applicable) *
Children's Ages (Please put 0 if applicable) *
How did you hear about this program *
Household YEARLY Income *
Are you receiving any Public Assistance? *
Do you have a New York State Driver's License? *
Do you have a computer at home? *
Can you access the Internet at home? *
Highest Education Level Completed *
Employment Status *
Last Employer: Please include Job Title/Company Name and Dates Employed *
Are you seeking Part-time or Full-time employment?
Clear selection
Salary Requirement *
After WERC Staff reviews your initial information, we will follow-up with you via the phone regarding additional questions/documentation to complete the registration process.
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