Name: |
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Address: |
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Phone: |
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Social Security # |
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Birth Date: |
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Race/Ethnic
Background: |
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Gender: |
Male
Female |
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| Veteran: |
Yes
No |
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Please provide the following information regarding your request for training assistance:
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Training Facility Name: |
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| Training Program: |
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| Start Date: |
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Type of assistance needed: (e.g. tuition, books, tools, uniform, gas stipend, daycare, etc.) |
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| If you are currently attending a training facility, list GPA:
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| Financial Aid: |
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| Receiving: |
PELL
OIG
Other (please specify) |
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| Applied for: |
PELL
OIG
Other (please specify) |
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| If marked "other", please specify below: |
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| Family Size:
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| Estimate of Family Gross Income for Last 6 Months:
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| Please check if you receive any of the following or if they apply: |
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Currently receives food stamps or received in the last 6 mo.
Homeless
Foster Child
SSI
Disability
OWF/TANF |
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| HAVE YOU LOST YOUR JOB DUE TO A PERMANENT LAYOFF OR CLOSING OF YOUR PLACE OF EMPLOYMENT?
YES
NO
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ARE YOU AN INDIVIDUAL WHO HAS BEEN PROVIDING UNPAID SERVICES TO FAMILY MEMBERS IN THE HOME AND HAS BEEN SUPPORTED BY THE INCOME OF ANOTHER FAMILY MEMBER, SUCH AS A SPOUSE, BUT HAS LOST THAT INCOME DUE TO DEATH, DIVORCE, OR OTHER REASONS?
YES
NO
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| ARE YOU UNEMPLOYED, UNDEREMPLOYED OR HAVING DIFFICULTY FINDING EMPLOYMENT?
YES
NO |
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| THIS AGENCY DOES NOT UNFAIRLY EXCLUDE INDIVIDUALS FROM OPPORTUNITIES OR MAKE DECISIONS BASED UPON RACE, COLOR, RELIGION, NATIONAL ORIGIN, POLITICAL AFFILIATION, AGE, OR DISABILITY. |
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| THE COMPLETION OF THIS APPLICATION DOES NOT CREATE ENTITLEMENT TO SERVICES AUTHORIZED UNDER THE WORKFORCE INVESTMENT ACT. |
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