Talent Up Fairfax Job Seeker Application

Step 1 of 4

25%

Name(Required)

First Middle Initial Last

Social Security Number

Gender

Date of Birth(Required)

MM slash DD slash YYYY

Address – Fairfax County residents ONLY can apply.(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Are you authorized to work in the U.S.?(Required)

Yes

Are you a Fairfax County resident?(Required)

Yes

Are you enrolled in the WIOA program?(Required)

Yes

Do you receive public assistance (TANF/SNAP)?(Required)

Yes

Please check the category that best describes the employment challenges you have faced related to COVID-19(Required)

If Other please explain

Are you Proficient in English?

Yes

If not, what language do you speak?

Are you a Veteran?

Yes

If yes, were you honorably discharged?

Yes

Do you consider yourself to be of Hispanic or Latino Heritage?

Yes

I do not wish to answer

What is your race?

African American/Black

American Indian/Alaskan Native

Asian

Hawaiian/Other Pacific Islander

White

I do not wish to answer

(Check all that apply)

The information below will help staff to better assist you in finding employment and will not be provided to employers.

Do you have a disability?

Yes

I would prefer to speak privately

If yes, check all that impact your ability to work

Physical

Mental

Learning

Sensory

Other

Have you even been arrested or convicted of a crime?

Felony

Misdemeanor

Other

What is your highest level of education?

Less than HS

HS Diploma/GED

Bachelor’s Degree

Master’s Degree

Higher than a Master’s Degree

If you have received post-secondary (beyond high school) education, please describe

Do you have an industry recognized credential(s)? Please list.

Are you currently employed?

Yes

If no, what was your last date of employment?

If no longer working, why did you leave the job?

Current/Most Recent Employer

Job Title

Wages

Wages Hourly or Annually

Hourly

Annually

Hours per week

How did you hear about this program?

Optional: Upload a copy of your current resume.

Accepted file types: doc, docx, pdf, Max. file size: 25 MB.

I certify that the information provided above is accurate. I understand I will need to provide verification of identity, right to work in the U.S., and residency in Fairfax County. I understand that I must provide confirmation of training completion and credential attainment if applicable.

Applicant Signature(Required)

Date(Required)

MM slash DD slash YYYY

CONFIDENTIALITY POLICY

It is the policy of the Virginia Career Works Northern Board to protect the confidentiality of all customer’s information.

Maintenance and Release of Data: Program Operators must collect data in order to document eligibility and provide services for Talent Up Fairfax. The Virginia Career Works - Northern Board will make every effort to collect and store data in a manner that ensures it will not be accessible to anyone without authorized access. Data collected will only be used to document eligibility or provide Talent Up Fairfax program services. Any other use of customer data will require written consent from the customer or customer's parent/legal guardian. Upon request, data can be released to the subject of the information.

Access to Data: Upon request, Virginia Career Works - Northern shall make available to the designated funding agency and its designated agents, as well as to government authorities and its designated agents, access to all documents and working papers. Access includes the right of designated agents to obtain copies of working documents, as is reasonable and necessary to determine compliance with and ensure enforcement of the provisions of the Talent Up Fairfax initiative.

Disclosure of Individual Identity: The identity of any individual who furnishes information relating to an investigation, compliance review, or customer satisfaction survey, including the identity of any individual who files a complaint, must be kept confidential to the extent possible, consistent with a fair determination of the issue. If it is deemed necessary to disclose an individual's identity, this individual must be protected from retaliation.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS POLICY. ANY QUESTIONS I HAVE REGARDING THIS POLICY HAVE BEEN ANSWERED.

Applicant Signature(Required)

Date(Required)

MM slash DD slash YYYY

EQUAL OPPORTUNITY (EO) RIGHTS NOTIFICATION

IMPORTANT! Below is important information about your rights, responsibilities and/or benefits. It is critical that you understand the information in this document, and we will provide the information in your preferred language at no cost to you. Please contact Virginia Career Works – Northern for assistance in the translation and understanding of the information in this document.

Equal Opportunity is the Law
This recipient is prohibited from discriminating on the grounds of race, color, religion, sex, national origin, age, disability, political affiliation or belief, and for beneficiaries only, citizenship or participation in programs funded under the Talent Up Fairfax program in admission or access to, opportunity or treatment in, or employment in the administration of or in connection with, any Talent Up Fairfax-funded program or activity. If you think that you may have been subjected to discrimination under the Talent Up Fairfax program or activity, you may file a complaint within 180 days from the date of the alleged violation with the recipient’s Equal Opportunity Officer: David Hunn, Executive Director, Virginia Career Works - Northern, 8300 Boone Boulevard, Suite 450 Vienna, VA 22182 or you may file a complaint directly with the Director, Directorate of Civil Rights (DCR), U.S. Department of Labor, 200 Constitution Avenue, NW Room N-4123, Washington, DC 20219. If you elect to file your complaint with the recipient, you must wait for the recipient issues a decision or until 60 days have passed, whichever is sooner, before filing with DCR (see address above). If the recipient has not provided you with a written decision within 60 days of the filing of the complaint, you need not wait for a decision to be issued, but may file a complaint with DCR within 30 days of the expiration of the 60 day period. If you are dissatisfied with the recipient’s resolution of your complaint, you may file a complaint with the DCR. Such complaint must be filed within 20 days of the date you received notice of the recipient's proposed resolution.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE NOTIFICATION ABOVE. ANY QUESTIONS I HAVE REGARDING THIS NOTIFICATION HAVE BEEN ANSWERED.

Applicant Signature(Required)

Date(Required)

MM slash DD slash YYYY

CONSENT TO EXCHANGE INFORMATION

I understand that different agencies provide different services and benefits. Each agency must have specific information to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

Client Name

Date of Birth

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Consent(Required)

I authorize Virginia Career Works-Northern and the Talent Up Fairfax Program, funded through the American Rescue Plan Act, to exchange employment information and education/training information with the following agencies: Talent Up Fairfax funding agencies including Fairfax County Department of Economic Initiative, Department of Family Services, Fairfax County EDA, Opportunity @ Work, regional employer associations, partner agencies/organizations of Virginia Career Worker-Northern, and training providers. I can withdraw this consent at any time by telling the referring agency. This will stop the listed agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, each agency will show me this information. If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they need. This authorization is good for one year after the completion of Talent Up Fairfax services unless otherwise requested in writing by the signatory.

Signature(Required)

Date(Required)

MM slash DD slash YYYY