Workforce Education Application
Worker Retraining, Workfirst, BFET, & Opportunity Grant
DATE: ____________
NAME: _____________________________________________________________ BIRTHDATE: ___________
(Last)
(First)
(MI)
ADDRESS: _________________________________________________________________________________
(Number & Street)
(City)
(State)
(Zip)
PHONE: _________________________________________ / _________________________________________
(Day)
(Evening)
E-MAIL ADDRESS: __________________________________________________________________________
SOCIAL SECURITY #: ______________________________ STUDENT ID #: ____________________________
Have you lived in Washington State for past 12 months?
Do you need a
Parking Permit
□
YES
□
NO
Bus Pass (Not available in all programs)
Current number of people you financially support in your household:
Self: 1
+ Spouse/Partner:
+ School-aged children:
+ Other: _____ = Total in household: _________
CURRENT GROSS HOUSEHOLD INCOME
Your earnings from work: $ ___________
Spouse/partner’s earnings: $ ___________
Child support: $ ______________________
Public Assistance: TANF: Yes / No
Unemployment Insurance: $_______/wk
Other Income: $ _____________________
circle one: BI-WEEKLY MONTHLY
OTHER: ____________
circle one: BI-WEEKLY MONTHLY
OTHER: ____________
circle one: PAID
RECEIVED
Basic Food: Yes/ No
Disability Lifeline: $_______/mo
Soc Security: $______/mo Veteran’s Benefits: $_______/mo
Source: ____________________ __________________________
EDUCATIONAL HISTORY
Course / Program of Study: ________________________________________ Program code (staff use only): ______
Education (circle one): Less than high school High school/GED Some college Degree/certificate:_________
FUNDING INFORMATION
Have you received Opportunity
Grant funding at any other
Washington State Community
or Technical College?
d
□
YES
□
NO
Are you planning on applying for any additional funding?
sd
□
□
TAA
□
WIA funding (TRAC/Pacific Associates)
Federal Financial Aid (FAFSA)
□
□
Veterans / GI Bill
Other: __________________________
AUTHORIZATION FOR RELEASE OF INFORMATION
We adhere to FERPA regulations regarding the privacy of student information. The information you give us is confidential. We will share it with our
WorkSource partners in order to give you access to employment and training services. Partners typically include Employment Security, the Department of
Social & Human Services (DSHS), the Division of Vocational Rehabilitation, community colleges, and other internal office staff of NSCC. Your signature
authorizes this release of information and certifies that the above information is true and correct to the best of your knowledge.
_______________________________________________________
(Student Signature)
_____________________
(Date)
_______________________________________________________
(Staff Member Signature)
_____________________
(Date)
ELIGIBILITY CODING (staff use only)
□ 76 (TANF – HW / HD and Health/IT)
□ 77 (TANF - employed 20+ hrs/wk)
□ 79 (TANF or Low-inc – ABE/GED/ESL, soft skills, not CJST)
□
□
□
□
80 (18+ mo. industry exp.)
81 (Less than 18 mo. industry exp.)
82 (Extended UI)
83 (Displaced Homemaker)
□
□
□
□
84 (Formerly self-employed)
85 (Former Boeing worker)
86 (Vulnerable Worker)
88 (Displaced Veteran)
STUDENT NAME: _____________________________________________ SID: ______________________
PERSONAL STATEMENT
Please describe your personal, academic and career goals.
Please describe how Workforce Education funding can help you overcome barriers and achieve those goals.
EMPLOYMENT AND TRAINING PLAN: ACADEMIC
Training Program: ________________________________________________________
Pre-requisite Classes
Goal of Training (select one):
Short-Term Training (one year or less)
Retraining for new career
Long-term Degree (more than one year)
Skill upgrade in current occupation
My goal is to get a job in my field of study by ____________ (Date: mm/yyyy)
EMPLOYMENT AND TRAINING PLAN: CAREER
Please list any/all job titles that you may be qualified for after completing your training.
______________________________________________
______________________________________
Please list the skills you will acquire in your training program to qualify for the position(s) above.
1._________________________________________ 2. _
______________________________________
3._________________________________________ 4. _
______________________________________
EMPLOYMENT AND TRAINING PLAN: PREVIOUS EXPERIENCE
Previous Occupation(s) and Employer(s):
_______________________________________________________________________________________
_______________________________________________________________________________________
Of Years at Most Recent Company: ________
# Of Years in Previous Occupation (any company): _________
Revised 3/10