Application for Employment Retraining Opportunity
Last Name First Name MI Student ID
City State Zip Code
Phone No.: County:
Company Name: Date of Layoff:
Address of Company:
Phone No.: County: Full Time Part Time
Term you plan to use ERO benefits New Student Returning Student
I certify that I have been permanently or indefinitely laid off from a full-time position within the past 12 months
from the employer listed above on the date indicated and that it was through no fault of my own. Additionally, I
have provided the appropriate documentation: a letter from my former employer on company stationery stating
the actual layoff date and that my job was lost through no fault of my own but due to the economic climate that
currently exists. I further certify that I am a resident of Lehigh, Carbon, or Schuylkill Counties or affected by a
Lehigh, Carbon, or Schuylkill County business or industry plant closing or layoff.
Should I become employed full time prior to the start date of the semester indicated, I will notify the Office of
Registration/Student Records immediately. I understand this will make me ineligible for this program.
I have read and understand the eligibility requirements on the reverse side of this form.
I understand that withholding information requested on this application or giving false information may make me
ineligible for admission to Lehigh Carbon Community College or subject to dismissal. I certify that the above
statements are correct and complete. I agree to abide by the rules and regulations of Lehigh Carbon Community
Signature of Student Date
Signature Signature Approved Date
Disapproved Date
Lehigh Carbon Community College will not discriminate against any employee, applicant for employment, student or applicant for admission on the basis of race, color, sex, pregnancy, political affiliation, religion, ethnicity,
national origin (including ancestry), citizenship status, disability, age, marital status, family responsibilities, sexual orientation, gender identity, veteran or military status (including special disabled veteran or recently separated
veteran), genetic information or any other protected category under applicable local, state or federal law, including protections for those opposing discrimination or participating in any grievance process on campus or within the
Equal Employment Opportunity Commission or other human rights agencies. Inquiries about this policy and procedure may be made internally to: Donna Williams, Director of Human Resources/Title IX/Equity Coordinator, Office
of Human Resources, 4525 Education Park Drive, Schnecksville, PA 18078, 610-799-1107, PERM44-e (4/10/15)
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