ANEW INFORMATION SHEET DATE:_____________ NAME:_______________ ADDRESS:____________ CITY: _______________ _________ STATE:______ ZIP:_______ PHONE:______________ Our program is funded by the Seattle-King County Private Industry Council which makes it necessary to follow federal low income guidelines. You must meet these guidelines in order to be eligible to apply to the ANEW program. The income eligibility requirements include earned income (wages) from six (6) months prior to your application date. Income from all family members must be counted including your parents’ income if you live with your parents. Do not include any monies received from AFDC, child support, GAU, SSI, et. cetera, or Unemployment Compensation in your calculations. Workmen’s Compensation payments are included as wages. To find your income level, look up the amount by finding the number in your family. Family members are your spouse and/or dependents. The amount allowed for that family size is on the chart below: Family Size 1 2 3 4 5 6 6 Month Income Guidelines $ 3,735 5,455 7,490 9,245 10,910 12,760 According to this chart, are you income eligible □ yes □ no If you are eligible, please fill out the other side of this information sheet. WORK HISTORY _____ Applicant:________ ____________ _____________ LAST name FIRST NAME DIRECTIONS: List all of the jobs which you have held and work backwards. NITIAL EMPLOYER STREET ADDRESS SOCIAL security NO starting with your current or most recent job DATE STARTED CITY STATE JOB TITLE DATE ENDED PHONE HOURS PER WEEK HOURLY wage $ 1 BRIEF DESCRIPTION OF DUTIES ANO RESPONSIBILITIES WAS THIS A JOB WITH AN EMPLOYMENT ANO TRAINING PROGRAM? □ □ YES NO WHY DIO YOU LEAVE? EMPLOYER STREET ADDRESS DATE STARTED CITY STATE JOB TITLE DATE ENDED PHONE HOURS PER WEEK HOURLY WAGE s 2 BRIEF DESCRIPTION OF DUTIES ANO RESPONSIBILITIES WAS THIS A JOB WITH AN EMPLOYMENT ANO TRAINING PROGRAM? □ □ YES NO WHY DID YOU LEAVE’’ EMPLOYER STREET ADDRESS DATE STARTED CITY STATE jOB TITLE • DATE ENDED PHONE HOURLY WAGE HOURS PER WEEK $ 3 BRIEF DESCRIPTION OF DUTIES ANO RESPONSIBILITIES WAS THIS A JOB WITH AN EMPLOYMENT ANO TRAINING PROGRAM? □ □ YES NO WHY DIO YOU LEAVE? EMPLOYER STREET ADDRESS DATE ENDED DATE STARTED CITY PHONE STATE JOB TITLE HOURLY WAGE $ HOURS PER WEEK 4 BRIEF DESCRIPTION OF DUTIES ANO RESPONSIBILITIES WAS THIS A JOB WITH AN EMPLOYMENT ANO TRAINING PROGRAM? □ □ YES NO WHY DID YOU LEAVE? EMPLOYER STREET ADDRESS DATE STARTED CITY PHONE state HOURS PER WEEK JOB TITLE DATE ENDED HOURLY wage $ 5 BRIEF DESCRIPTION OF DUTIES ANO RESPONSIBILITIES WAS THIS A JOB WITH AN EMPLOYMENT ANO TRAINING PROGRAM? □ YES □ NO WHY DIO YOU LEAVE’’ DATE STARTED EMPLOYER STREET ADDRESS STATE CITY HOURS PER WEEK JOB TITLE 6 BRIEF DESCRIPTION OF DUTIES ANO RESPONSIBILITIES WAS THIS A JOB WITH AN EMPLOYMENT ANO TRAINING PROGRAM? □ □ YES NO WHY DID YOU LEAVE’’ DATE ENDED PHONE HOURLY WAGE S