Dislocated Worker Program Application

This program is voluntary. If you are receiving Unemployment benefits, enrollment or denial due to program eligibility will NOT affect your Unemployment benefits. Incomplete or illegible forms may delay contact.

First name*

Last name*

Street address*

City*

Zip Code*

County*

Select

Email*

Phone number*

Veteran or spouse of a veteran?*

Select

Most Recent: Employer and Job Title*

Select the one that describes your situation:

Select

If Other, please describe:

Eligible for Unemployment Insurance?

Select

Do you think you will return to your previous job*

Select

What assistance do you need to return to work?

Have you worked in the same occupation for 6 months within the last three years?*

Select

How many hours per week were you working?*

How long have you been job searching?*

Select

Acknowledgment

All forms will expire 30 days upon reception. If you do not reply to the Dislocated Worker Program counselor’s attempt to reach you, another interest form will need to be completed. By clicking the submit button, you: • are giving us permission to contact you regarding the Dislocated Worker program and agreeing to share your information with the City of Minneapolis and its partners • understand that you are being asked to provide private information to enable Dislocated Worker program staff to assist you. you understand this information may be shared with others as allowed by law but only after you have received and signed the full Department of Employment and Economic Development Notice How We Use Your Personal Information. You further acknowledge and understand that all data entered is subject to the Minnesota Government Data Practices Act. • acknowledge that by electing to receive your information via email in a non-secure manner that the information will not be encrypted, and that it could be intercepted & viewed by a third party. The City of Minneapolis is not responsible for unauthorized access to your information while in transmission to the email address you designated above.

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