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First Name
Last Name
Last four digits of social security number
Date of Birth
Street Address
City
State
Zip
County
Email Address

Are you a person with a disability? yes no

Do you need any support or assistance to use equipment or access services? yes no

I have not served in the military

I have served in the military

I may be an eligible spouse of a veteran (The spouse of a person who: a) was killed in action or who died of a service connected disability; b) is serving on active duty who is listed as 1. missing in action, 2. captured in the line of duty, or 3. forcibly interned in the line of duty for a total of 90 days or more; or c) has a permanent total service connected disability)

Equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Michigan Relay Center (800) 649-3777.

You will receive your Northwest Michigan Works! membership card in the mail within about one week.

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