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  • RAPID RE-EMPLOYMENT APPLICATION

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  • COVID STATUS

    HAVE YOU SUFFERED AN ADVERSE FINANCIAL CONSEQUENCE AS A RESULT OF YOU OR A MEMBER OF YOUR HOUSEHOLD BEING AFFECTED BY COVID19? IF YES, HAS THAT FINANCIAL LOSS AFFECTED YOUR ABILITY TO ENTER EMPLOYMENT OR TO MAINTAIN EMPLOYMENT?
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  • RELEASE OF INFO AUTHORIZATION

  • I * UNDERSTAND THAT THE RAPID RE-EMPLOYMENT PROGRAM NEEDS TO RECEIVE INFORMATION CONCERNING MYSELF AND/OR MY FAMILY AND IS ASKING FOR COOPERATION IN THIS PROCESS. I DO GIVE MY CONSENT TO THE CINCINNATI-HAMILTON COUNTY COMMUNITY ACTION AGENCY, URBAN LEAGUE OF GREATER SOUTHWESTERN OHIO, EASTER SEALS, AND CINCINNATI WORKS TO RELEASE THE INFORMATION FOR THE PURPOSE OF CLIENT ASSISTANCE, ETC. AND UNDERSTAND THAT MY INFORMATION MAY BE SHARED WITH PARTICIPATING AGENCIES. I UNDERSTAND THIS CONSENT FOR RELEASE OF INFORMATION SHALL REMAIN IN EFFECT FOR ONE YEAR, UNLESS I REVOKE MY CONSENT TO THIS AGREEMENT. 

  • EMPLOYMENT CONFIRMATION

  • I,*,AGREE TO INFORM THE RAPID RE-EMPLOYMENT PROGRAM UPON OBTAINING EMPLOYMENT. I GIVE PERMISSION TO THE RAPID RE-EMPLOYMENT PROGRAM TO VERIFY MY EMPLOYMENT STATUS, INCLUDING PAY AND BENEFIT INFORMATION THROUGH DIRECT ACCESS WITH MY EMPLOYER.

  • I DECLARE THE INFORMATION SUBMITTED ON THIS APPLICATION IS TRUE AND CORRECT.

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  • I DECLARE THAT THE CLIENT VERBALLY CONFIRMED THE ACCURACY OF THE CONTENT OF THIS APPLICATION.

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