APPLICATION FOR GAP TUITION ASSISTANCE

GAP TUITION ASSISTANCE

APPLICATION
BASIC INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*
SSN Last 4*
Gender*

MaleFemaleOther
Gender*
Ethnicity

African AmericanAsianHispanicAmerican IndianWhiteOther
What is your Native Language?
Ex: English, Spanish, Other
Are you a U.S. Citizen?*

YesNo
Are you legally eligible to work in the United States?*

YesNo
Are you a veteran, current or former member of the U.S. Armed Forces?*

YesNo
Are you the spouse or child of a veteran?*

YesNo
ELIGIBILITY
What is your marital status?*

SingleMarriedDivorcedWidowed
Do you have any children or dependents that you claim on your income tax return?*

YesNo
How many children or dependents?*
What are the ages of your children or dependents?
Do you receive assistance from the state (such as Food Assistance, Title 19, etc)?*

YesNo
Has your income significantly changed since filing your recent federal income tax return?*

NoYes
If yes, please explain
You will need to provide a copy of your Federal or State Income Tax Return you filed or were claimed on.
EDUCATION
What is your highest level of education completed?*

College DegreeHigh School DiplomaGEDHSED
What is the date you received your highest level of education?
Name of school and location*
Highest grade completed*
What additional training or education do you have?*
EMPLOYMENT
What is your current employment status?*

EmployedSelf-EmployedNot EmployedEmployed with Notice of SeperationUnderemployed (working less than 30 hours per week or any number of hours per week in a job below your skill level)Dislocated Worker/Laid-Off
What types of employment challenges have you experienced within the last year? (Please select all that apply.)*

Basic Skills DeficientCultural BarriersDisability and/or Chronic Physical/Mental Health ConditionsDomestic ViolenceHomelessness/Unstable HousingEx-OffenderFoster Care YouthDisplaced HomemakerFirst-Generation College StudentImmigrantLack of Child CareLack of Health Insurance or Access to HealthcareEnglish Language LearnerLow Level of LiteracyLow IncomeMigrant and/or Seasonal FarmworkerPoor Work HistoryPregnancyParentingSubstance Abuse (past or present)Unreliable TransportationOther
Do you have a current up-to-date resume?*

YesNo
Attach a copy of your resume if you want your resume reviewed.

Cancelof
Please rate your interviewing skills (5 - Outstanding and 1 -Poor)*

54321
Please rate your interviewing skills (5 as outstanding and 1 as poor)*
Please explain why you selected your rating.*
Are you proficient with computer skills?*

YesNo
If yes, please list your skills.

Microsoft WordExcelOther
Have you ever been arrested, charged or convicted of a misdemeanor, felony or other pending charge?*

YesNo
Since you answered yes to the question regarding arrests and convictions, please select all that apply:*

MisdemeanorFelonyPending Charge
Please describe the legal problem(s) as indicated above.*
Have you ever needed or do you currently need substance abuse assistance?*

YesNo
Appointment Date?
WORK HISOTRY

(Work history can include volunteer work, part-time employment and self-employment.)
Current or Most Recent Employer*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Date Started*
Last Day Worked*
Total Hours Per Week*
Job Duties*
Reason for Leaving*
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Date Started
Last Day Worked
Total Hours Per Week
Job Duties
Reason for Leaving
PROGRAM RESEARCH
How did you learn about GAP Tuition Assistance?*
What GAP Program(s) are you interested in?*

Accounting ClerkAdministrative Office & Computer SpecialistAdvanced Emergency Medical Technician (AEMT)Beef TechnicianBookkeeper CertificationCertified Nurse Aide (CNA)Custodian - MaintenanceDigital & Social MediaDrone (UAV) Commercial Application & OperationElectrical MaintenanceEmergency Medical Technician (EMT)Grain HandlerIndustrial Maintenance TechInventory Control SpecialistMedication AidePayroll SpecialistProfessional Applicator Certificate (Agronomy)Tower TechWater TreatmentWeldingWorkplace Computing
What GAP Program are you interested in?
Signature - Applications are valid for 6 months from date of signature

I certify that the information I have provided on this application is true to the best of my knowledge. I am also aware that the informatio I have provided may be reviewed and verified, and that I may have to provide documents to support this information. I allow release of this information for documentation puruposes.

Further, I understand that this information will be used to determine my eligiibility for the Gap Tuition Assistance program. I am aware that I am subject to immediate termination and that I may be prosecuted for fraud and/or perjury if I am found ineligible after enrollment.
Signature*

Clear
Date*
Should be Empty:

GAP TUITION ASSISTANCE

BASIC INFORMATION

ELIGIBILITY

EDUCATION

EMPLOYMENT

WORK HISOTRY

PROGRAM RESEARCH