THIS IS CONFIDENTIAL DATA AND CAN ONLY BE USED FOR THE ADMINISTRATION AND DELIVERY OF FEDERAL/STATE FUNDED PROGRAMS ...
DOL NISGTC TAACCCT GRANT
PARTICIPANT APPLICATION FORM THIS IS CONFIDENTIAL DATA AND CAN ONLY BE USED FOR THE ADMINISTRATION AND DELIVERY OF FEDERAL/STATE FUNDED PROGRAMS
IDENTITY: PLEASE PRINT Name: _________________ First
_____ MI
Mailing: _____________________ Address
______________________ Last ____________ City
__________ State
________________ Suffix
Application Date: ____ -____ -_____ MM DD YYYY
__________ Zip Code
County __________________
___________ Zip Code
County __________________
If residence address is the same as mailing check this box Residence: ____________________ ____________ _________ Address City State Home Phone: ____ -____ -____ Cell Phone: ____- _____- _______ SSN: _____-______ -_______
Student ID: ______________
E-mail address: ____________________________ Birth Date: ____ -____ -_____ MM DD YYYY
Emergency Contact: PLEASE PRINT Name: _________________ First
_________________ Last
Phone: ____ -____ -____ Ext._____
Email address: __________________________
CHARACTERISTICS - Check boxes Gender: Male Female
Ethnicity – Hispanic/Latino Yes No
EDUCATION: (Select Highest Grade Completed) Some High School Some College Post-Secondary Vocational/Skills Credential
Race (Select all that apply) 1. White 2. Black or African American 3. American Indian or Alaskan Native High School Diploma/GED Associates Degree Bachelor’s Degree Master’s Degree
4. Asian 5. Native Hawaiian or Other Pacific Islander
DOL NISGTC TAACCCT GRANT
List Special Courses Taken or Certifications (Military, vocational, technical) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Do you have limited English speaking, writing, or reading abilities? Yes No MILITARY HISTORY Veteran Status (DD214/215 or other proof required) Yes No Spouse of a Veteran EMPLOYMENT STATUS Select the one that describes your current employment status: Employed at ___________________ Employed at _______________ but Occupation____________________ received Notice of Termination
Not Employed
Unemployment Compensation Status Select the one that best describes your current unemployment compensation insurance (UI) status: I am eligible for and claiming UI The job I have been terminated from (or have received a Notice of Termination) is a UI covered job I have exhausted my UI Is not a UI covered job and I am looking for work None of the above Current Wage/Salary or Unemployment Wage Hourly Wage $_________
Hours Work per Week __________ OR
Annual Gross Salary/UI Wage $________________
Are you TAA Eligible?
Yes
No
Do not know
Are you Pell Eligible?
Yes
No
Do not know
DISABILITY/MEDICAL If you require special assistance or accomodations please contact the Disability Services Office (361) 698-1292.
DOL NISGTC TAACCCT GRANT
Training Goals Enrollment Plan Program
Full time
Part time
Geographic Information Systems
What is your educational goal?
Certificate
Cybersecurity Degree
Network & Data Communication
Programming
Undecided
What types of jobs do you hope to obtain after completing your training? ______________________________________________________ _____________________________________________________________________________________________________________________ What interests you about this Program of Study? ___________________________________________________________________________ _____________________________________________________________________________________________________________________ I certify all statements and attachments on this form are true to the best of my knowledge and will be used to determine eligibility for the training program services. I understand it is my responsibility to submit any changes in writing for change of address, phone number, employment, pay status or course of study, etc. For research purposes to meet reporting requirements related to the U. S. Department of Labor TAACCCT grant, I authorize Del Mar College to use any information about me related to my academic record ( including withdrawal , enrollment status, and degrees/certifications enrolled in and obtained, etc.) and my employment record (including retention, earning outcomes, etc.). Del Mar College will fill in my social security number on the release to the Texas Workforce System on the next page and will use my social security number only for obtaining employment data through them (as described in the TWC form below.) My social security number will be transmitted in an encrypted manner. I understand that any information personally identifying me will be removed before any data about me will be transmitted to the University of Illinois for purposes of national research regarding the U.S Department of Labor program.
Del Mar College is an equal opportunity institution and provides education and employment opportunities without discrimination on the basis of race, color, religion, gender, age, national origin, disability or veteran status. For more information contact Disability Services Office at (361) 698‐1292. For persons with hearing or speech impairments, please call V/TDD at (361) 698‐2192. V/TDD at (361) 698‐2192. “This workforce solution was funded by a AUTHORIZATION TO RELEASE grant awarded by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The CONFIDENTIAL EMPLOYMENT RECORDS Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy, continued availability or ownership.”
DOL NISGTC TAACCCT GRANT
I,
,
Social Security Number:
,
authorize the Texas Workforce Commission (“TWC”) to release the following records: Employment records during the last quarter Date of employment Wage or earnings during the last quarter NAICS code for the employer (identifies the industry designation of the employer) to the following person/entity: Workforce Solutions of the Coastal Bend / Del Mar College I understand that these are records of a state agency, and I expressly authorize that agency to release these records to the above person/entity for the following purpose: U.S. Department of Labor TAA grant to track employment, placement and retention during the contract period. I authorize the release of records for use only for the purpose listed above. Any person(s) obtaining records pursuant to this Authorization shall be solely responsible for the payment of all costs assessed by the Tex as Workforce Commission for providin g such re cords. A leg ible photocopy or telecopy transmission facsimile of this Authorization shall be deemed equivalent to the original. This Authorization shall be valid for a period of four (4) years from the date of execution set forth below, or until my written revocation is received by TWC, whichever occurs earlier. My signature on this form indicates my consent to these terms and my commitment to participate in the program. Date: ____________________________________________ Signature: __________________________________________________________________ Printed Name: _______________________________________________________________
Texas Workforce Commission, Open Records Section ● 101 E. 15th Street, Room 266 ● Aus n, Texas 78778‐0001 ● Tel: 512‐463‐2422 ● Fax: 512‐463‐2990 ● Relay Texas: 800‐735‐2989 (TDD); 800‐735‐2988 (Voice) ●
[email protected] ● www.twc.state.tx.us Equal Opportunity Employer/Services
