WERC Enrollment/Intake Application

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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 *

Application Date *

YYYY

Name *

19 13v1961Date of Birth *

YYYY

Address include Street, City, State, and Zip code *

County of Residence *

Phone Number *

Race / Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern

Native Hawaiian or Other Pacific Islander

White

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? *

Are you currently receiving Unemployment Insurance? *

Yes

Are you receiving the monthly Child Tax Credit at this time? *

Yes

Do you have a New York State Driver's License? *

Yes

Do you have a computer at home? *

Yes

Can you access the Internet at home? *

Yes

Highest Education Level Completed *

Employment Status *

Please list your last employer including Job Title/ Company Name and Dates Employed *

Are you seeking Part-time or Full-time employment? *

Part-time

Full-time

Salary Requirements *

$15.00 - $17.00 per hour

$17.00 - $20.00 per hour

$20.00 - $23.00 per hour

$24.00 per hour and above

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