Adult/Dislocated Worker Referral Form

Is translation assistance needed?*

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Primary Language*

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Customer Name:*

First NameLast Name

Birth Month

Birth Day

Pronoun(s) Used

She/HerHe/HimThey/ThemNot Listed (Please Type)

Customer - Preferred Contact Method (for follow-up with you)*

EmailPhone CallTextIn-Person

Customer - Preferred method of services:*

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Customer Phone Number

Please enter a valid phone number.

Do you consent to receive text messages from your employment specialist (you will not receive any spam)*

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WARNING!

If you select no, you will be unable to receive text messages from your employment specialist for the duration of the program unless you choose to refill a consent form.

Customer Email

example@example.com

Customer County of Residence*

What other state do you currently reside in?*

Preferred Office?*

EverettLynnwood

Customer - are you a veteran or the spouse of a veteran?*

YesNo

Where did you hear about this program?*

Case Manager Name (Workfirst or DVOP)*

First NameLast Name

DVOP/Workfirst Case Manager Phone Number*

Please enter a valid phone number.

DVOP/Workfirst Case Manager Email*

example@example.com

Which Resource Room were you referred by?*

EverettLynnwood

MIS Number

ETO Number

Organization Name:*

Program Name*

Program Name (other)*

Your Name*

First NameLast Name

Your Preferred Method of Contact*

PhoneEmailI do not wish to be contacted

Your Phone Number

Please enter a valid phone number.

Your Email

example@example.com

Select All That Apply:*

In need of specialized trainingUnderemployed and need to upgrade skillsBeen out of the workforce and in need of assistance to reenterNeed help identifying career goalsHave a job offer and in need of employment related assistance

EQUAL OPPORTUNITY IS THE LAW

It is against the law for this recipient of federal assistance to discriminate on the following bases:

Against any individual in the United States, on the basis of race, color, religion, sex (including pregnancy, childbirth, and related medical conditions, sex stereotyping, transgender status, and gender identity), national origin (including limited English proficiency), age disability, or political affiliation or belief; or,
Against any beneficiary of, applicant to, or participant in programs financially assisted under the Title 1 of the Workforce Innovation and Opportunity Act (WIOA), on the basis of the individual’s citizenship status or participation in any WIOA Title 1 – financially assisted program or activity.

The recipient must not discriminate in any of the following areas:

Deciding who will be admitted, or have, access, to any WIOA Title 1 – financially assisted program or activity;
Providing opportunities in, or treating any person with regard to, such a program or activity; or
Making employment decisions in the administration of, or in connection with, such a program or activity.

What to do if you believe you have experienced discrimination:

If you think that you have been subjected to discrimination under a WIOA Title 1 – financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either:

Local Equal Opportunity Officer

Workforce Snohomish

808 134th St. SW, Suite 105

Everett, WA 98204

425-921-3415 / Rely 711

State Equal Opportunity Officer

Employment Security Department

P.O. Box 9046

Olympia, WA 98507-6046

360-902-9354 / Relay 711

Director, Civil Rights Center (CRC)

U.S Department of Labor Room N-4123

200 Constitution Ave NW

Washington, D.C. 20210

202-693-6502

TTY: 202-693-6515

If you file a complaint with the recipient, you must wait until the recipient issues a written Notice of Final Action or until 90 days have passed (whichever is sooner) before filing a complaint with the CRC (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with the CRC. However, you must file your CRC complaint within 30 days of the 90- day deadlines (in other words, within 120 days after the day on which you filed complaint with the recipient).

If the recipient does give you a written Notice of Final Action on your complaint but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 300 days of the date on which you received the Notice of Final Action.

WorkSource is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Washington Relay 711

By signing, I attest that I have read and understood the Equal Opportunity form*

Date*

Date

Summary

WorkSource is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. WA Relay 711

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