REFERRAL FORM
FOOD STAMP EMPLOYMENT AND TRAINING/OPTIONAL WORKFARE PROGRAM

SECTION A:  GENERAL INFORMATION	
Participant's Name		Case #	
	Date		
	
Mailing Address	

City		State		Zip Code		Telephone #	(   )	     	
	
Participant's Status	  MANDATORY	  VOLUNTARY				
	
Sex		Date of Birth		Highest Grade Completed	  	
	
The above referenced participant is currently enrolled in the Food Stamp Employment and Training Program or the Optional Workfare Program.	

SECTION B:  REFERRED FROM	
Staff Name	
	Agency		
	
Address		City		State		
	
Zip Code		Telephone #				

SECTION C:  REFERRED TO	
Agency	

Address	     	
	
City	     	State	  	Zip Code	     	Telephone #	(   )        	
	
Reporting Date	     		Reporting Time	     	AM PM	

SECTION D:  RESULTS		Complete Sections D and E and return to originator in Section B.	
  Registered	  Entered Employment (Complete Section E)	  Entered School/Training	
	
		Name of School		
  Failed to Report	  Reported - Did not complete application	Location		
		Start Date		
	
Training Program		
	
No Suitable Service Available/Explain		
	
Comments:		

SECTION E:  EMPLOYMENT INFORMATION	
Employer		
	
Address		City		State		Zip Code		
	
Telephone #		Start Date		
	
Job Title		Hours/Week		Wage $		
	
Employment Verified By		Date Verified		Signature		

AWI-FSET 4163, 07/2007