DWD Interest Form

Interest Form
Name*

First NameLast Name
Date*

MonthDayYear
Date
How can we contact you?

PhoneEmailOther
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How many hours would you like to work per week?*
Do you have any concerns about losing benefits due to hours of work?*

YesNo
Which benefits?*

Food stampsSSIUnemploymentTANFOther
Would you like to work more than 2 hours per week?*

YesNo
How many hours per week can you work?*
What kinds of work experience/skills do you have?*
What is your educational background (or highest attained)?*
What is your current living situation?*
Please select any obstacle(s) you have that may prohibit you from working more*

TransportationPhysical/mental limitation or disabilityLegal issuesOtherNot Applicable
Please list the obstacle(s) that were not listed*
Do you have the documents required to legally work in the US? (ex. govt issued ID, social security card, passport, etc.)*

YesNo
Which of these documents do you have?*

Government issued IDValid drivers licenseSocial security card (or receipt from SSA)Passport
If not, what is the status of these?*
What assistance are you currently receiving?*

Food stampsApple HealthTANFCash assistanceSSDISSINoneOther
May we include a headshot for our files? If so, please upload a picture below*

YesNo
Please select or capture an image:*
Should be Empty: