First Name _ Last Name _____ Last 4 digits of SS# __________
Address ________________
City County Zip ____
SHORT-TERM CERTIFICATE SCHOLARSHIP
INFORMATION APPLICATION
Home Cell ______
Work E-Mail _____________________
Currently Employed: Yes No Receiving Unemployment: Yes No
Employer _____________________
Job Title ________ Current Annual Wage ___________
EDUCATIONAL HISTORY:
Graduated High School: Yes No
GED: Yes No
Some College: Yes No
College Degree: Yes No Associate Bachelor Master Major/Program
_________________
Computer Experience: Yes No
OFFICE USE ONLY:
Course #: _________
Start Date: _________
End Date: _________
:
Date of Birth ___________ Number in Household ________
Male Female Former Foster Youth: Yes No
U. S. Citizen: Yes No Veteran: Yes No Disabled: Yes No
(Males Under 25) Registered with Selective Service: Yes No
Ethnicity:
Black/African American Hispanic/Latino
White Asian American
Native Hawaiian or other Pacific Islander Multiracial American Indian/Alaska Native
Signature Today’s Date __
Was your employment impacted by Covid-19?
Yes No
If yes, were you:
Laid off /terminated Hours reduced
workforce training
