NJ HealthWorks Application Scaling Apprenticeship

Application Date*

Date

Site College *

Salutation *

First Name*

Middle Initial *

Last Name*

Birthdate*

Date

Gender *

Email *

Home phone *

Mobile*

Other Phone*

Best Way to Contact (please select one)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race*

Ethnicity *

Marital Status *

US Citizenship *

If you are not a US Citizen, do you have a greencard/proper working documents?

YesNo

Disability Status*

Ex-Offender Status *

Are you a veteran?*

YesNo

If a veteran*

Highest Level of Education Achieved*

Highest grade completed*

Interested in which program(s)*

Program Start Date

Date

Program End date

Date

Are You Currently Attending School?*

If Enrolled in School, What is Your Current Program/Major

What School Are You Currently Attending?

If Currently Attending School, When Did You Start?

Date

If Currently Attending School, When Do You Graduate?

Date

What are your current educational plans? *

Currently employed?*

Yes, full time (35+ hours)Yes, part timeYes, per diemNo

Current Employer (applicant)*

Have you been with this employer for six months or longer?*

YesNo

Job Title*

Hourly Wage at Intake *

Average hours work per week*

Do you consider yourself underemployed?*

YesNo

If considered underemployed, please select those that appy.*

Unemployed Benefits *

Are you a NJ SNAP participant? New Jersey's Supplemental Nutrition Assistance Program

YesNo

Secondary Contact Name*

First NameLast Name

Secondary Contact Email*

example@example.com

Secondary Contact Phone Number*

Area CodePhone Number

Secondary Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Contact Relationship to Applicant*

Privacy Statement

Information collected during the enrollment process will be used for official business only to fulfill U.S DOL’s reporting requirements, your individual data will never be reported and data will only be used in aggregate or anonymized. You will be asked to document your employment after program completion. Additional data may be needed throughout the grant period and will be collected through questionnaires and/or surveys. Your privacy and the information you provide will be safeguarded and stored in accordance with Federal requirements.

Privacy Act

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Labor is authorized to collect information to implement the Trade Adjustment Assistance Community College and Career Training Program under 19 USUC2372 -2372a. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing this information, including social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information that is collected will be retained in the program files of the grantee and may only be released to other Department officials in the performance of their official duties.

Disclaimer

New Jersey HealthWorks Scaling Apprenticeship is sponsored by a $12 million dollar grant from the U.S. Department of Labor, Employment and Training Administration (Federal Award ID. No. (FAIN): HG-33026-19-60-A-34). The US DOL grant includes additional match funds amounting to over $500,000 to support OJT and other employer assistance from the New Jersey Department of. Labor and Workforce Development GAINS Project.

I certify that the information on this application is accurate, true, and has been provided voluntarily. I understand that false or misleading information given in my application or interview(s) can result in disqualification from the program(s).

NJ HealthWorks Grant Application