Southern Illinois Workforce Development Board
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AJC INTAKE FORM with Veteran INFO — 221109

TODAY'S DATE(Required)
Preferred Service Location (select one):(Required)
Name(Required)
Address(Required)
Email(Required)
Date of Birth(Required)
I live in the following County (check one):(Required)

Have you done farm work in the last 24 months, or are you a dependent of someone who has done farmwork in the last 24 months?(Required)
Have you served in the military, or are you a spouse of a Veteran?(Required)

Veteran (Section A)

Before completing Veteran Sections A, B, C, and D, shown below, please download and review the Veteran Eligibility Triage Form Definitions Document (PDF file, 276 KB).
What was your Character of Service at discharge?

Veteran (Section B)

If you check any of the boxes or answer "YES" to any of the questions in this section, you may be eligible for additional services, if desired.
Are you an eligible VETERAN who served between the years 1961-1975 and meets one of the following:
Are you an eligible VETERAN aged 18 to 24?
Are you a Transitioning Service Member who attended a Transition Assistance Program (TAP) workshop, and:
Are you a wounded, ill, or injured Service Member receiving care at a Warrior Transition Unit (WTU) or Military Treatment Facility (MTF)?
Are you a CAREGIVER for a wounded, ill, or injured Service Member receiving care at a WTU or MTF?

Veteran (Section C)

If you check any of the boxes in this section, please proceed to Section D and mark all applicable options.
Are you a VETERAN who:
Are you the SPOUSE of a Veteran who:

Veteran (Section D)

If you check any of the boxes in the section below, you may be eligible for additional services, if desired.
Are you an eligible VETERAN or eligible SPOUSE (check all that apply):

I need help with the following (select all that apply):

EDUCATION
EMPLOYMENT
PERSONAL BARRIERS
LEGAL SERVICES
AUTHORIZATION TO RELEASE INFORMATION(Required)
NOTE: Referrals will be sent within 24 hours.
Reset signature Signature locked. Reset to sign again
By signing and/or submitting this form, customer has self-attested and acknowledges their status as listed in the sections above.

 

Southern Illinois Workforce Development Board

3117 Civic Circle Boulevard, Suite B
Marion, Illinois 62959

Ph: 618-998-0970

Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities.

Information regarding the funding source of workforce grants awarded by the Illinois Department of Commerce and Economic Opportunity using federal funds from the United States Department of Labor can be found at this link: https://www.illinoisworknet.com/ fundinginformation

 

Recent News

  • Terance Henry, SIWDB Chair and IT Director for City of Marion, speaks at Illinois Digital Government Summit
  • REGISTER TODAY! Workforce Summit — October 4th — Mt. Vernon, Illinois
  • Kathy Lively, CEO at Man-Tra-Con Corporation, announces plans to retire by the end of the year.
  • Governor Pritzker and DCEO Announce $20 Million Investment to Boost Equitable Workforce Recovery
  • Intertape Polymer Group selected as a Top Ten Finalist for Industry Week’s 2022 National Best Plants Award.

Archived News

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