Scholarship Application Checklist - rjuhsd.us · Scholarship Application Checklist ... (see Form I-9 for a complete list of qualifying documents) ... What is the status of your claim:

Scholarship Application Checklist Create a CalJOBS Account (www.caljobs.ca.gov) Complete the Questionnaire Complete the Master Application Complete the Training Award Application Packet

(1) Employer Interview (1) Employee Interview (2) School Visits

Sign the Release of Information

Bring Proof of Household Income Bring DD214 (for veterans) Bring Right to Work Documents (see Form I-9 for a complete list of qualifying documents) Contact Information Golden Sierra Job Training Agency 115 Ascot Drive, Suite 180 Roseville, CA 95661 916-746-7722 or CA Relay 711 [email protected]

Golden Sierra is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. To request a reasonable accommodation, please call (916) 746-7722 ext. 106 at least 72 hours prior to event.

TDD/TTY users please call the California Relay Service at 711.

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Please use ink. Fill out form completely before interview appointment. Eligibility does not guarantee services.

Last Name First Middle Last 4 SSN

Street Address: City State Zip

Mailing Address: City State Zip

Home Phone Number: Cell Phone Number:

E-mail:

Date of Birth: Age:

Provide verification (i.e. CA Driver’s License)

Citizenship: U.S. Citizen or Legal Resident: # Provide copy of INS Document

Alternate Contacts - List Two Contacts

Friends or family members who know how to contact you

Full Name: __________________________________________ Relationship: __________________

Mailing Address: _______________________________________________________________ City State Zip

Phone Number: __________________________ Email: ______________________________

AND

Full Name: __________________________________________ Relationship: ______________

Mailing Address: ___________________________________________________________ City State Zip

Phone Number: _________________________ Email: _____________________________

Questionnaire & Self Attestation

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Military Service

If you are a male born on or after January 1, 1960, over age 26 and have not registered for Selective Service, you are not eligible for WIOA funded services unless you can prove you were exempt. You may obtain a printout of your number by contacting the Selective Service on the web at www.sss.gov

A. Have you registered for selective service? [ ] Yes [ ] No

B. If No, and you are a male, were you born on or after January 1, 1960? [ ] Yes [ ] No

C. If exempt, please explain:

D. Have you ever served in the military/armed forces? [ ] Yes [ ] No Which Branch?

E. List assigned duties & training received:

F. Were you on active duty for more than 180 days? [ ] Yes [ ] No Discharge Date:

G. Type of Discharge: Honorable_ Dishonorable Medical_ Other

H. Are you in the reserves? [ ] Yes [ ] No

I. Considered a Disabled Veteran? [ ] Yes [ ] No

J. Planning to enlist in the military or reserves? [ ] Yes [ ] No Which Branch?

Education and Previous Training

A. In school now? If yes, name of school and program: _

B. Planning to attend school or training? [ Yes [ ] No When and where? _

C. High School Diploma: [ ] Yes [ ] No GED: [ ] Yes [ ] No Last Grade Completed:

D. College Degree(s) & Major/Minor or number of units:

E. Other Training Certifications:

MILITARY SERVICE, EDUCATION & TRAINING

http://www.sss.gov/

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Check all that apply to you:

Lack of transportation Need for repairs Pending court case

______Lack of car insurance Criminal record Overdue child support payments ______Suspended driver's license

Probation/parole

Unpaid traffic tickets ______Other (list)

A. Explain any items that were checked above:

B. Do you have any pending legal issues? [ ] Yes [ ] No If Yes, explain:

C. Have you ever been convicted of a misdemeanor and/or a felony? [ ] Yes [ ] No

D. If yes, what was the nature of the offense?

E. How long ago? Were you incarcerated? [ ] Yes [ ] No For how long?

F. Are you currently on probation or parole? [ ] Yes [ ] No Upcoming court dates?

G. Name and phone number of probation/parole officer:

H. Valid driver’s license? [ ] Yes [ ] No Type: Passenger Motorcycle Class A Class B

I. If you are not eligible for a driver’s license, please explain:

J. Any moving violations in the past 3 years? [ ] Yes [ ] No

K. If yes, How many? When?

L. For what?

M. Have you had any “Driving under the Influence” violations in the past 10 years? [ ] Yes [ ] No

N. Describe your mode of transportation:

O. How far are you willing to commute to a job or training program?

TRANSPORTATION & LEGAL ISSUES

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Check the item(s) that currently apply to you:

Lack of childcare Inadequate clothing

Housing problems Soon to be a parent Lack of family support Lack of food Must move soon Homeless Single parent Living in transitional housing Other Separation/Divorce

A. Explain any items checked above:

B. Have you applied for Workers Compensation? [ ] Yes [ ] No

C. What is the status of your claim: Expiration/Closed Date of Claim:

D. Are you currently being assisted by any other agency? [ ] Yes [ ] No

If Yes, which one(s)?

Contact name(s) and phone number(s):

E. Are you eligible for or have you exhausted your unemployment insurance (U.I.)? [ ] Yes [ ] No

F. When did you originally file? When does your U.I. Expire?

G. What else have you and your household lived on for the last six months? H. Are you receiving services or have you received services from any of the following providers?

(Please check all that apply to you)

Workers Compensation _Private Rehabilitation Other

PRIDE Industries _M.O.R.E.

CA Dept. of Vocational Rehabilitation (DOR/VR)

I. Please check the items that apply to you:

Financial problems Explain:

Difficulty with money management Explain: _

Heavy debts Explain:

Lack of current source of income Explain:

Outstanding Student Loans Explain:

Other:

CURRENT CIRCUMSTANCES

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Including you, please list the people in your household, their relationship to you, their age, and approximate income during the last 6 months:

Name Relationship to

You Age Total Gross Income $

(previous 6 months) Source

SELF

Circle All That Apply

Wages/salaries (gross income) Self-employment (net income) Money from odd jobs Social Security retirement Social Security Disability (SSDI) Military reserve pay Military retirement Other Veteran's benefits Private pensions

Workers Compensation State or private disability (SDI) Union strike benefits Royalties Alimony Support from absent family member Cash from family or friends Non-needs based college grants College scholarships/fellowships

Training stipends Work study wages Dividends or interest earned Rental income Annuity payments Gambling or lottery winnings Severance pay

Trust or estate payments Inheritance Compensation for injury Insurance proceeds

Active duty military pay Unemployment Income CalFresh / Food Stamps TANF / General Relief Loans

Supplemental Security Income (SSI) Child support payments Foster childcare payments Withdrawal from savings Pell Grants (needs based)

Proceeds from sale of property/belongings Social Security Survivor’s Benefits Tax refunds Cash gifts Capital gains

FINANCIAL

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This worksheet is to help you determine if a training program is appropriate for you at this time. Please complete the following to demonstrate how you will be supporting yourself during training.

Monthly Current Expenses

Monthly Expenses While in Training

Rent / House Payment Gas / Electricity Telephone Water / Garbage Groceries Lunch Money Car Payment Gas / Oil / Upkeep Car Insurance Bus Passes DMV Fees Child Care House Repairs / Upkeep Property Taxes Personal Grooming Clothing Diapers Medical Schooling / Seminars Loan Payments Credit Card Payments Cable TV Internet Newspapers / Magazines Entertainment Shopping / Gifts Church / Donations Child Support Alimony Legal Fees Student Loan Payments Other

What additional expenses do you expect during the next year?

Current While in Training Monthly Income: Monthly Income: Monthly Expenses: Monthly Expenses: Balance: Balance:

BUDGET

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Self-disclosing may qualify you for additional services and supports.

A. Do you have a disability? [ ] Yes [ ] No

Please describe any assistive technology, accommodations and/or assistance you may need in order to perform the essential functions of a job:

B. Check all that apply to you and provide a brief explanation Staff Comments

Allergies:

Upcoming surgery:

Physical limitations:

On-going physical / mental / emotional health issue(s):

Previous or current alcohol issues:

Previous or current drug issues:

Vision problems:

Hearing problems:

Speech problems:

Need for medical / vision / dental care:

Counseling needs:

In counseling (individual, peer or group):

Take regular medications:

Are there any additional health or medical issues that we need to be aware of? [ ] Yes [ ] No

HEALTH & MEDICAL

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Dislocated Worker Terminated or Laid Off (A, B, and C)

A. Has been terminated or laid off, or has received a notice of termination or layoff, from employment; B1. Is eligible for or has exhausted unemployment insurance ; or B2. Is not eligible for unemployment insurance, but has demonstrated attachment to the workforce; and C. Is unlikely to return to a previous industry or occupation.

Permanent Closure of Substantial Layoff (A or B)

A. Has been terminated or laid off, or has received a notice of termination or layoff, from employment as the result of any permanent closure or substantial layoff; or B. Is employed at a facility where the employer has made a general announcement that the facility will close within 180 days.

Self-Employed

A. Was self-employed but is currently unemployed as a result of general economic conditions or natural disasters.

Displaced Homemaker (A, B, and C) A. Has been providing unpaid services to family members in the home; B. Is unemployed or underemployed and experiencing difficulty finding employment; and C1. Has been dependent on the income of another family member but is no longer supported by that income; or C2. Is the dependent spouse of a member of the Armed Forces on active duty and whose family income is significantly reduced because of a deployment, a call or order to active duty, a permanent change of station, or the service-connected death or disability of the member.

Eligible Spouse (A and B) A. Is the spouse of a member of the Armed Forces on active duty who: B1. Has experienced a loss of employment as a direct result of relocation to accommodate a permanent change in duty station of such member; or B2. Is unemployed or underemployed and experiencing difficulty finding or upgrading employment.

Adult

Priority of Service Groups (A, B, or C) A. Recipient of public assistance B. Low income individual (see WSDD-119)

1. Receives, or in the past 6 months has received, or is a member of a family that is receiving or in the past 6 months has received, assistance through SNAP, TANF, SSI or income-based public assistance.

2. Has received a BOG community college fee waiver within the past school year. 3. Total family income does not exceed the poverty line or 70% of the LLSIL. 4. A homeless individual. 5. An individual with a disability whose own income does not exceed the income requirement.

C. Basic skills deficient (see WSDD-119) 1. Lacks a high school diploma or GED and is not enrolled in secondary education. 2. Enrolled in Title II Adult Education/Literacy program. 3. English, reading, writing, and computing skills at an 8.9 or below grade level.

D. Unemployed or underemployed per current guidelines.

EMPLOYMENT CIRCUMSTANCES

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Items Generally Used as Documentation Alternate documents may be accepted upon approval

Photo ID: Driver’s License (State), Military ID card, School ID, Passport Age: Birth Certificate, Driver’s License, Passport SSN: Social Security Card Selective Service: Registration verification printout from website (www.sss.gov) Public Assistance: Current public assistance printout, Cal Fresh records Disability: School I.E.P., DOR certification, SSI printout, medical certification Family Size: Rental agreement, birth certificate listing parents, proof of disability (family of 1) Income: Pay stubs (previous 6 months) Termination: Termination letter / Closure notice Unemployment: Award letters from EDD and a recent UI paystub

I understand signing the Media Release is voluntary and services are not dependent upon applicant consent.

I consent to participation in interviews, the use of quotes and the taking of photographs, movies or video tapes.

I also grant Golden Sierra Job Training Agency the right to edit, use, and reuse said products for purposes including use in print, on the internet, and all other forms of media. I also hereby release the Golden Sierra Job Training Agency and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

Signature of Applicant Date

I certify that the information provided in this questionnaire and self-attestation is true to the best of my knowledge. I am aware that this information will be used to help determine my eligibility for Golden Sierra Job Training Agency services. I understand that there is no guarantee that I will receive services or training.

Signature of Applicant Date

Printed Name

CERTIFICATION

MEDIA RELEASE

DOCUMENTATION

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Master Application/Eligibility

(Last) (First) (Middle)

(Address) (Cell Phone)

(Email Address) (Home Phone)

EDUCATION Name of School Location of School Degree or Course of Study Date Completed

EMPLOYMENT HISTORY (most recent job first)

Job Title Dates Worked From To Pay $ Per

Employer Supervisor

Address

Telephone Number Reason for Leaving

Duties Performed


Employer Supervisor

Address


Duties Performed

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Employer Supervisor

Address


Duties Performed


Employer Supervisor

Address


Duties Performed

MILITARY SERVICE RECORD

Branch Discharge Date

PERSONAL REFERENCES (list the names of three references)

Name Telephone Relationship

Address

Name Telephone Relationship

Address

APPLICANT STATEMENT I certify the information in this application is true to the best of my knowledge.

Signature Date

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Training Award Application Name: Date Completed:

Requirements:

1. You may want to apply for a Training Award if you are unable to pay for training. 2. All training programs, prior to being considered for a grant/scholarship, must be on

the CalJOBS WIOA training provider list and willing to contract with GSJTA. (http://www.caljobs.ca.gov/training.asp)

3. All training programs should prepare skilled workers for employment in high- demand industry clusters. Occupational skills training in other valued industries may be considered on a case by case basis.

4. All training programs should prepare skilled workers for career pathways that lead to self-sufficiency. Self-sufficiency is defined as employment that pays at least 100% of the current Lower Living Standard Income Level (LLSIL) as published by the State of California Employment Development Department (EDD).

Instructions:

1. Please complete the following forms as thoroughly as possible. 2. Completed forms will be submitted to a Training Award Committee for review. The

Committee is responsible for the selection and disbursement of all financial awards.

3. Please keep in mind, the thoroughness of your answers and presentation of your application will reflect directly on your chances of receiving a Training Award.

4. Type or print all information in INK. 5. If you have questions or need assistance, please contact your case manager.

Application Completion Checklist: 1. I have completed my Personal Information Worksheet. 2. I have completed Employee Informational Interviews. 3. I have completed Employer Interviews for current openings. 4. I have completed Vocational School Interviews. 5. I have provided a copy of my high school diploma or GED and any

applicable college transcripts (if required). 6. I have provided a copy of my driver’s license and proof of auto insurance. 7. I have demonstrated a labor market for my training occupation by providing

copies of local job announcements.

http://www.caljobs.ca.gov/training.asp)



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Golden Sierra Job Training Agency Training Award Application

PERSONAL INFORMATION

WORKSHEET Applicant’s Name:

First Middle Last Home Phone: Alternate Phone:

1. Please provide a summary of your past work experience:

2. Why is it necessary for you to change your career path?

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3. Why did you select this occupation?

4. Why do you believe you will be successful in this occupation?

5. What is the estimated growth of this occupation?

6. What are your opportunities for advancement in this occupation?

7. How will you ensure that you will complete the training program?

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8. How will you support yourself during the training program?

9. How will you go about finding employment?

10. Are you willing to relocate to secure employment? If so, how far?

11. How will you overcome your lack of on-the-job experience?

12. If you are receiving Unemployment Insurance (UI), have you applied for

California Training Benefits (CTB)? Yes No

* NOTE: You must apply for CTB prior to your 16th week of receiving UI

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Participant Name:

Date of Interview:

Golden Sierra Job Training Agency

Training Award Application

EMPLOYEE INFORMATIONAL INTERVIEW An informational interview provides an opportunity for you to visit or contact a place of business that interests you, and allows you to talk to people working in that career sector. Please be sure to answer each question below as thoroughly as possible.

Employer: Location:

Person Interviewed: Phone:

Job Title:

1. What do you do in a typical day?

2. What skills and personal characteristics do you need to do this job?

3. What education, work experience or certification is required for this job?

4. How did you get started in this field?

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5. What is the normal starting wage?

6. What is the growth potential in this occupation?

7. What do you find satisfying about your job?

8. What is the hardest part of your job?

9. What is the best path to get into this field?

10. Do you know if there are any open positions at your place of business? If so, who

would I contact?

11. What advice would you give a person entering this field?

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Participant Name:

Date of Interview:


EMPLOYER INFORMATIONAL INTERVIEW An employer informational interview provides an opportunity for you to visit a place of business that interests you and allows you to talk to the owner or a manager. Please be sure to answer each question below as thoroughly as possible.

Section A (Please complete the following prior to calling employer.)

Business Name: City:

Position Calling About: Phone:

Job Description:

Physical Requirements:

Section B (Questions to ask employer.)

Person Interviewed: Title:

1. What kind of experience are you ideally looking for in a candidate?

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2. What key personal characteristics do you look for in candidate?

3. What is your hiring process?

4. I will soon be graduating from a vocational school, what advice would you give

me entering this field?

5. What are your experiences hiring from vocational schools?

6. Which school/s would you recommend?

7. Do you have any current openings for this position? Yes No 8. Do you expect any openings in the near future? Yes No

9. Additional Information?

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Participant Name:


SCHOOL SELECTION WORKSHEET Name of school: Date:

Contact Person: Title:

Phone & extension: Email:

Name of program (attach course outline):

Start dates (next 2-3): End dates:

Training schedule (days/hours):

Total cost (attach breakdown of tuition, books, fees, etc.):

Financial aid available: Pell SEOG_ Loans_ Scholarships_ Other_

Progress reports process: Contact:

Required entrance exams: Refund policy (attach printout):

Course requirements outside of class (homework or other assigned projects, estimate

number of hours per week) Explain:

Attendance policy:

Tools/Supplies needed:

Where do graduates find jobs?

Are placement services provided? If yes, what does that entail?

What is the training provider placement rate?

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Authorization for Release of Confidential Information

Name of Consenting Participant

This release is a voluntary consent that allows Golden Sierra Job Training Agency to make employment inquiries, obtain records, and/or enter into discussions with the organizations listed below regarding its participants.

Employment Development Department Maximus Department of Rehabilitation NorCal Services for Deaf and Hard of Hearing Department of Health and Human Services Los Rios Community College District Department of Veterans Affairs Sierra College Department of Housing and Urban Development Area 4 Agency on Aging County Office of Education Experience Works County Probation Department Small Business Development Center Social Security Administration California Employers Association LiteracyPro/CommunityPro Suite Lake Tahoe Community College Other: Other: Roseville Adult School

I understand the information released will be used in order to assess, plan, and facilitate the delivery of services for my benefit. I hereby authorize my training provider to release academic records such as attendance, grade reports, and graduation status.

In addition, I give permission to Golden Sierra Job Training Agency to contact my current and former employers in order to verify my employment status (i.e. start date, job title, hourly wage, and hours per week). This release will expire 3 years from the date of signature.

I hereby certify that I have read and received a copy of this release.

Participant’s Signature Date

Signature of Parent or Guardian (if participant is under age 18) Date