WERC Enrollment/Intake Application
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Email *
Application Date *
Name *
19 13v1961Date 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? *
Are you currently receiving Unemployment Insurance? *
Are you receiving the monthly Child Tax Credit at this time? *
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 *
Please list your last employer including Job Title/ Company Name and Dates Employed *
Are you seeking Part-time or Full-time employment? *
Salary Requirements *
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