Applicant Information

Employment Information


Military Service

Public Assistance


Individual Barriers

Career Pathway Information


Certification: My signature below indicates that I have been informed of and understand the information contained on this form. I certify under penalty of perjury that all the above information is true and complete. I agree that any information I have supplied is subject to verification. I understand that falsification of any item could result in termination from the program and may result in action to recover any moneys paid to me while participating.

I authorize CSPBC staff to register me in EmployFlorida and/or re-enrollment me in Wagner-Peyser in order to provide me with services leading, but not limited to, job referrals, employment, training, and support services. This authorization is good throughout the entire WIOA participation (including the follow up period after closure).

By typing your name below, you agree that will be used as your signature.

If Applicant is under the age of 18, Parent/Guardian information is also required.