Name _____________________________________ Todays Date ___________________
Address: ___________________________________________ Cell Phone: ________________________
E-Mail Address:_____________________________________ Home Phone:______________________
Social Security Number: ______________________________ Alternative Phone: _________________
Are you a Veteran? _________________
Orleans County Job Development Agency
Training and Career Plan Assessment
This questionnaire is designed to help both you and the Office of Workforce Development with your career plans.
Take your time and think about the questions and your answers. Proper, realistic choices at this stage in your life are
critical and we want you to make the right choices.
This packet is also a large part of the case that you are making for yourself on why your training should be funded as well as
presenting your motivation towards training. We hope that some of these questions will bring out answers you may not have
thought of yourself.
Please answer all questions completely or put N/A if it does not apply to you, then sign at the end of the application and
return to us with the supportive documentation.
Our funding is limited and decisions are based on the projected success and need of the applicant. Funding for training is not
a guarantee even if all paperwork is returned. Your application for training funds will be reviewed and a decision will be based on a
number of factors including: need for funding, prior experience and skills, completeness & timeliness of paperwork, review of testing,
related records & documentation, and availability of funds. A decision will be made based on all these factors and the application for
funding will be approved or denied by the Department Director.
Please sign and date that you have read and understand the above statement.
Signature: ______________________________ Date: _____________
CAREER PLANNING
In what career would you like to being trained? ______________________________________________
Will this be an “upgrade of skills” for your current occupation or a “change in careers” for you?
Upgrade in Skills Change in Careers
Please fill out the section appropriate to your choice.
“Upgrade in Skills”
Why do you feel that this upgrade is necessary?
___________________________________________________________________________________________
Will this training result in a change of job title and pay rate? If so, what title and what rate?
___________________________________________________________________________________________
“Change in Careers”
Why have you chosen this new career instead of continuing on in your old field?
___________________________________________________________________________________________
Why do you think you’re suited for this type of work, & will this training build on skills & experience you
already have?____________________________________________________________________________________
__________________________________________________________________________________________
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How have you explored this career? List all your activities in career planning including any career interest inventory tests, personality
inventory, or skills assessment tests and the results. If you haven’t done anything yet then how do you know this field is right for you?
___________________________________________________________________________________________
Name some drawbacks to this kind of work. How will you handle these drawbacks?
___________________________________________________________________________________________
Do You know what the average starting wage is for this occupation? $ ______________ per ___
Is the Occupation in Demand? ______Yes No______
How far are you willing to travel One Way to a job each day? _____ miles (ex: Rochester to Albion is 35 miles)
How many openings do you think are there for this type of job? _______
Can you think of at least 4 different places you would be qualified to work upon completion of the training?
_______________________________________________ ____________________________________________
_______________________________________________ ____________________________________________
PRIOR EMPLOYMENT EXPERIENCE
What previous jobs have you had in the last 10 years? (Job title, company or attach resume)
Job Title Wage Company From: Dates To:
__________________ ___________ _____________________________________ ___________________
__________________ ___________ _____________________________________ ___________________
__________________ ___________ _____________________________________ ___________________
__________________ ___________ _____________________________________ ___________________
What Training and/or Education do you have? (or attach resume)
___________________________________________________________________________________________
___________________________________________________________________________________________
JOB SEARCH
Are you currently employed? _____ No _____ Yes Where? __________________________________
Rate of pay? $ __________ per _____
(If “yes” Skip to Barriers)
If unemployed: How long have you been out of work for? _______________
What do YOU think are your strengths, skills and weaknesses? & Why do you think you haven’t been hired yet?
___________________________________________________________________________________
___________________________________________________________________________________
POSSIBLE BARRIERS
Some issues can affect your ability to gain or perform employment in your chosen field.
Many occupations require mandatory background checks and/or physicals.
Due to this, we need to know what barriers you may have.
How reliable is your transportation? What backup do you have?
___________________________________________________________________________________________
If necessary, who will provide childcare? Who is your backup?
__________________________________________________________________________________________
Social Support: Are your family members supportive of your decision to seek training? If not, how will you handle that?
________________________________________________________________________________________________
_________________________________________________________________________________________________
Yes No: Legal. Do you have ANY prior felonies, misdemeanors or family court issues now or in your past?
(Please note that we reserve the right to run background checks on applicants and ask for more information.)
If Yes, list court issue: ______________________________________________________________________________
Yes No: Are there any health issues now or in your past that would affect you getting employment in your chosen
field? (Example: weight restrictions, stand/sitting restrictions, limited mobility issues, vision/hearing difficulties). If so, please
provide a doctor’s note that these restrictions will not prevent you from performing the duties of your job with reasonable
accommodations.____________________________________________________________________________________
Yes No: Are there any DMV issues now or in your past that would affect you getting employment in your chosen
field? If you are applying for CDL truck driver training, attach a background check from the DMV._________________
Additional Eligibility Questions
To comply with Federal reporting requirements for Workforce Investment Act funded programs, we are required to collect
additional personal information from customers when they begin receiving a more intense level of service. In addition, under the
American Recovery and Reinvestment Act of 2009, individuals who are low income or public assistance recipients must receive
priority for service under certain aspects of our programs. The provision of this additional information is VOLUNTARY. Staff will be
happy to assist you to complete this questionnaire.
Number of people (including self) in the household related by blood or marriage: ______
Total yearly household income for above counted individuals: $_________________
Yes No Are you a Veteran or a Spouse of a Veteran?
Yes No Do you or are you a member of a family that receives public assistance? If so check all that apply
TANF Food Stamps
General Assistance Medicaid
Section 8 Housing Supplemental Security Income (SSI-SSA)
Refugee Cash Assistance
Yes No If you or your family are not receiving public assistance, do you believe you or your family might
meet low-income criteria? If yes, what is your total family income $ __________ per _______
Yes No Are you a person with a disability whose own income might meet low-income criteria?
If yes, what is your income? $________ per __________
Yes No Were you involved in a large layoff of either: 25% of employee at company or 50 or more workers
were laid off?
Yes No Did the company you work for close?
Yes No Are you on unemployment? If yes, what is your weekly UI benefit?_____________________
Yes No Were you a stay at home parent (or employed part time), supported by the income of another
family member, but are no longer supported by that income and find that you must now return
to work full-time to help support the household? (This could include a family member losing a job,
divorce, separation, and death in the family)
Yes No Is your native language a language other than English?
If so, please indicate your native language: ______________________
Yes No Do you have difficulty speaking, reading, writing or understanding English?
Yes No Are you a single parent?
(Single, separated, divorced or widowed with primary responsibility for one or more dependent children under age 18)
Yes No Are you homeless? (Lack a fixed, regular, adequate nighttime residence, or is your primary nighttime residence a
publicly or privately operated shelter)
Yes No Are you currently a foster child?
Yes No Are you an offender? Definition: Have you been subject to any stage of the criminal justice process for committing
a status offense, or have a record of arrest or conviction [ANY Felonies or misdemeanors EVER]
Applicant Certification
My signature below certifies that all information provided on all parts of this Assessment is true and
correct to the best of my knowledge. I understand this information is used to determine eligibility and I may be
required to document the accuracy of this information. This information is subject to external verification and
may be released for such purpose.
I understand that any falsification or omission of information within this packet will automatically
disqualify me from consideration for funding.
If found ineligible after enrollment, I understand I will be terminated from the program. If I am
terminated as a result of falsifying information on this assessment, I understand I may also be prosecuted for
fraud and/or be required to reimburse any money spent. My signature serves as giving my permission to verify
any and all information contained in this assessment.
I understand that funding for training is not a guarantee even if all paperwork is returned.
My application for training funds will be reviewed and a decision based on a number of factors including:
need for funding, prior experience and skills, completeness & timeliness of paperwork, review of testing,
related records & documentation, and availability of funds. I understand that a decision will be made based on
all these factors and the application for funding approved or denied by the Department Director.
I understand that if I choose to start a training program without being approved for funds prior to the
start of training, I will not be eligible for funding for that program even if my financial situation changes during
the course of the program.
I attest that, as of this date, I have the resources to begin and complete this training program once I
am approved for training funds. Additionally, by signing below I certify that I am currently earning less than
$20 an hour.
Signature of Applicant Date
When this form is completed, you may bring it to our office located on the first floor, across from the DMV,
in the Orleans County Administration Building, or mail it to the attention of:
Orleans County Career Center
Orleans County Job Development Agency
14016 Route 31 West
Albion, NY 14411
For questions, please contact us at 585-589-2772 or email OCJDA@orleansny.com.
Equal Opportunity Employer and Provider
A proud partner of the
Network
Updated 12/30/2019 from Version Dated 12/28/2017
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