Employment & Training Profile Sheet
Version 11/2020
Name: D.O.B:
If you would like to attend a training program (must end in a certificate,
license, or diploma), please provide the information below:
Name of School or Training Program:
Length of training program:
Beginning date:
Ending Date:
Achievement: Diploma Certificate License Other
Reason for your request (attach supporting documentation):
Have you have any difficulty obtaining employment due to a previous
misdemeanor or felony record? If so, please explain:
Name other sources of funding you’ve applied for:
Fund amount $
Total fund amount
When applicable, you must provide:
Copy of any certifications, licensures, diplomas and/or degrees
Enrollment/Registration Information
Once program is completed, you must hand in these documents (when
Copy of program certificate or licensure
Receipts for approved expenditures
For Office Use Only:
Approved Staff Initial Denied
Source: P.L. 102-477 TGF