Training
Screening Tool

5230 West US Highway 98
Panama City, Florida 32401
(850) 872-3853

Date:  
Program of Study:  
First Name:  
Middle Name:  
Last Name:  
Birthday:  
Home Phone Number:  
Work Phone Number:  
Cellular Phone Number:  
Email:  
Street Address:  
City:  
County:  
State:  
Zip:  
Have you ever received assistance from JTPA before? Yes  No
Have you lived in Florida for the past 12 months? Yes  No
Are you currently in school? Yes  No
Marital Status: Married       Single
Divorced     Widowed
Number of dependents (including self).
Are you a citizen of the United States or authorized to work in this country? Yes    No
Employment status: Employed
Unemployed
What is your approximate before taxes family income?
Do you have a . . . ?
 		 Felony
Misdemeanor
None
Do you have limited understanding of Enlish? Yes
No
Public Assistance Status (Welfare, TANF): Applied for     Receiving
 Not Applicable
Food Stamp Status: Applied for     Receiving
 Not Applicable
Unemployment Compensation Status: Applied for        Receiving
 Not Applicable  Exhausted Benefits
Education Level: Less than High School
 Highest grade completed
 High School Diploma/GED
AA/AS Degree
BA/BS Degree
 MA/MS/Ph.D/Ed.D Degree
List Field of Degree:  





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