Employment Assistance Program Application

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Thank you for your inquiry with the Employment Assistance Program in requesting assistance to attend Workforce Development Courses in the vocational and technical field. The program staff commends you for setting educational goals that will provide skills in upgrading or obtaining employment. In order for the program to assist you in your education goals, it is important that you return your application and the listed items below, before the start of the Workforce Development course.

Please submit a copy of the following information:

• Official High School Transcript or GED scores

• MBCI Certified Degree of Indian Blood (CDIB)

• Drivers License or a Picture ID.

• Social Security Card

• Information and Cost of the class you are interested in attending

Please answer all question & submit all required documents before the starting date of each Workforce Developme Course. An incomplete application will delay the processing of your application.

Application Date

Social Security Number

Telephone Number

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Community

Gender

Date of Birth

Age

Are you a member of the MBCI?

CDIB#

Marital Status

Number of Dependents

Children In School

Please List Each Member of Household

In most Workforce Development courses a GED or High School Diploma is not required but preferred.

Emergency Contact Person *

First

Last

Emergency Contact Phone Number

Other Contact Information

Do you have a high school diploma or GED?

If "No," please estimate date of completion of High School or GED

Have you ever been convicted of a felony?

If "Yes," please explain

Do you have any physical limitations that would interfere with attending Workforce development classes?

If "Yes," please explain

Have you attended a Workforce development class before?

If "Yes, please list the class/classes taken, date taken, and whether you completed the course

Please list the type of Workforce development class/classes you would be interested in:

Please explain how will the Workforce development class/classes will benefit your employment skill:

Education

Elementary School Name

Location

City/State

Years Completed

High School Name

Location

City/State

Years Completed

Did You Receive a Diploma?

College/Vocational Education

Location

City/State

Years Completed

Did You Receive a Diploma?

Previous Employment

1. Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Position

Duties

Date Employed

Reason for Leaving

2. Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Position

Duties

Date Employed

Reason for Leaving

3. Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Position

Duties

Date Employed

Reason for Leaving

I hereby apply to attend the school indicated on this application and agree to follow all rules and regulations and attendance requirements of the school and to the best of my ability will satisfactorily complete the required course which I have selected in the Workforce Development Program.

I authorize the school to release grades, attendance reports, and income verification information to the Employment Assistance Program personnel.

Signature

Clear Signature

Privacy Act and Paperwork Reducation Act Statement:

1. The authority for solicitation of the information on this fi.mn is 25 U.S.C. 13 (42 Stat. 208) and P.L. 84-959 (70 Stal. 986) as amended by P.L. 88-230 (77 stat. 471. 25 U.S.C. 309).

2. Disclosure of the requested infonnarion by the applicant is voluntary. but required to obtain benefit.

3. The purpose of this infomiation collection is to determine your eligibility for services.

4. The routine use of this information is by th.: Employment Assistance Program employee's to evaluate your request and to assist you before and during your training. After completion of training. or if this application is for Direct Employment. parts or all of the infom1ation in your application will be provided 10 employers who are considering you for employment. The application will be used in a routim: manner by counselors working with you who need background infonnmion and by those people involved in financial control who need budgeting infomiation comained in the application.

5. Failure to provide requested infonnation may result in a delay or denial in receiving training or job placement assistance you are seeking.

I have read the above statement. I hereby provide the required information and authorize the use of such information to the extent of the uses specified in the statement.

Signature

Clear Signature

Today's Date

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