Qualifications for Funding

Name

First Last

Parish where you currently live:*

Primary Phone*

Alternate Phone

Email Address that is checked often:*

Phone Number that is available to receive Text Message:*

Which Registered Apprenticeship program did you apply with?

Which of our partners referred you for eligibility determination?*

Employer (Please provide the name of the Employer)
Training Provider (School)
Union
Other (please specify below)

If Other, please specify

Please name the employer, organization, union, or training provider, if applicable.

What is your current employment situation?*

I am not currently working
I am currently working full-time (more than 30 hrs a week)
I am currently working part-time
I am currently working full or part-time for a Temp agency
Other

If Other, please specify

Please answer the following questions to assist us in determining your eligibility as a "dislocated worker" Please answer each question carefully and accurately.

Are you a recently separated veteran?

Yes
No

Are you the surviving spouse of a veteran who is eligible for VA benefits?

Yes
No

If you indicated that you are a recently separated veteran, please indicate your date of separation.

Are you receiving or have you exhausted unemployment benefits?

Yes
No

Were you laid off in the last 7 years and now making less wages than before?

Yes
No

Did your previous employer close or go out of business?

Yes
No

Did you work less than 20 hours a week in your last job?

Yes
No

Was your last employer a temporary employment agency?

Yes
No

Are you not likely to return to your previous occupation with the skills you currently have?

Yes
No

Were you self-employed, but the economy or a natural disaster has put you out of business?

Yes
No

Have you been dependent on the income of another family member and are no longer supported by that income; and are unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment?

Yes
No

Please complete the following for additional eligibility consideration:

Do you or someone in your household receive Food Stamps (SNAP):

Yes
No

Do you or someone in your household receive Welfare Assistance (TANF):

Yes
No

Number of family members in household (including yourself):

Approximate household gross income for the past 6 months (includes all contributing members of the household):

Do you have a disability? (This will not disqualify you.)

Yes
No
Prefer not to answer

I certify that the information provided is true and accurate to the best of my knowledge. Please enter today's date*

Thank you for completing the pre-eligibility application. If you are determined eligible you will be contacted by your local Business and Career Solutions Center to complete your application and provide the following documentation: > Valid Driver's License or State ID > Social Security Card > Proof of citizenship (birth certificate or passport) > Employment history, including dates of employment > If a male over the age of 18, Selective Service verification > If a veteran, DD-214

Please tell us about your career interests to help us better understand your needs. Also, feel free to let us know if you have any questions or concerns that you would like to have answered by a staff member of the Business and Career Solutions Centers.*

Registered Apprenticeship Form

Please refer to http://careeronestop.org for additional information about Business & Career Solution Centers