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WORKER RETRAINING ELIGIBILITY APPLICATION
APPLICANT INFORMATION
Name:______________________________________________
Preferred Name:______________________________________
Date:
Date of Birth: SSN: SID:
Street Address:
City Zip: Phone: Alt Phone:
Email: (print clearly) Are you a Washington resident?
(Living in WA 1 or more years)
Yes No
EDUCATION INFORMATION
Program of
AAS Certificate
Study:_____________________
Other___________________
Program Start
Projected End
Date:______________________
Date:__________________
Will you be attending:
Full-time (12+ credits
)
3/4 time (9-11 credits)
Part-time (6-8 credits)
Have you previously or are you currently receiving
Worker Retraining services from any school?
Yes No
Currently enrolled in classes at SPSCC?
Yes No
What is your highest level of education?
Less than HS Certificate of Completion Bachelor’s Degree
HS Diploma or GED Associates Degree Post Bachelor’s Degree
If you do not have a degree, how many college credits have you earned?
NONE 1-30 31-45 46-90 91 or more
OTHER INFORMATION
Yes No
Military Veteran honorably discharged within past 48 months?
Are you active military with an order of separation?
Are you currently receiving unemployment benefits?
Have you exhausted unemployment benefits within the past 48 months?
Are you eligible for unemployment benefits?
Displaced homemaker within past 48 months?
If yes, household size ______, and total family income per month: $__________ (include spouse or parents if applicable).
Were you self-employed but now unemployed due to economic factors?
Currently working but have received written notice of layoff?
Are you currently employed?
Is your employer requiring more training or skills and you have not yet earned a certificate/degree?
Have you previously been laid-off and are now working a temporary job?
Signature of
Date:
Applicant:
(updated 01-29-18 DHC)
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signature
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