Re-Employment Services and Eligibility Assessment (RESEA) Program

Intake (INT) Form

Please complete this form to begin your participation in the RESEA program.

WD-49

Today's Date

One-Stop Office As indicated on your RESEA selection notice Value is not selected

Interview Date As indicated on your RESEA selection notice

Verification Code As referenced in the RESEA orientation presentation

First Name

Last Name

Email Address

Phone Number

Do you consent to receive SMS notifications? Check 'No' if unsure or landline

Yes

No

Are you currently employed? Value is not selected

Name of employer

Status Value is not selected

Return to work date current or past date

Is this a new or former employer? Value is not selected

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