PFS Application

Work History

Labor Force Status: Please check your status and complete the information below
Are you currently employed?*

YesNo
Are you currently receiving unemployment benefits?*

YesNo
Number of weeks on unemployment
Complete the information below for the last two jobs you have held. Start with the most recent position. Include Military and Volunteer work.
Job Title
Dates of employment:

MonthDayYear
From
MonthDayYear
To
Company
Supervisor
Phone
Address

Address

Street Address Line 2

CityState

Zip
Hours/Week
Hourly wage
Reason for leaving
Job Title
Dates of employment:

MonthDayYear
From
MonthDayYear
To
Company
Supervisor
Phone
Address

Address

Street Address Line 2

CityState

Zip
Hours/Week
Hourly wage
Reason for leaving
Certification of Applicant:
I certify that the information provided is true to the best of my knowledge. I am aware that the information provided is sub ject to review and verification and that I may have to provide additional information. I authorize Partners to share this information with Partners For Success Partners (ie. Tribal Court, L-A High School, LA Connections, Employment & Training, PFS Higher Ed., Grants Cibola County Schools) for the purpose of assisting me in obtaining assistance, training, education or employment.
Applicant's Signature*

Clear
Date

MonthDayYear
Parent/Guardian's Signature

Clear
Date

MonthDayYear

Personal Statement for Services
A personal statement will reflect your atttude, commitment to completing a program, and your short and long-term goals. All statements must be typed. Here are some subjects you should cover in your personal statement:
- Education Goals: What type of degree or certificate do you plan to earn?
- Employment Goals: What type of work will you seek upon completion?
- Describe your personal commitment or desire to complete a program.
- Any personal achievements that you would like to note.
- Previous Education.
Remember, this statement is simply a short, three-paragraph document that allows Partners for Success to understand your commitment towards completing the training in which you are interested. It should explain exactly why you are requesting services from Partners for Success.

You may bring a physical copy of your personal statement to the PFS office to accompany your application, or email it to: p.solimon@lagunaed.net

If you need assistance, please call 552-9322
Upload your Personal Statement file:

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Example files: Word, PDF
Cancelof

W-9

Request for Taxpayer Identification Number and Certification
Name (as shown on your income tax return)*
Address

Number, street, and apt. or suite no.

Street Address Line 2

CityState

Postal / Zip Code
Check the box below:*

Individual/Sole Proprietor

Social Security Number*

	#	#	#	#	#	#	#	#	#
SS#

Signature of U.S. person*

Clear
Date*

MonthDayYear

Media Release
I, TYPE YOUR NAME* , do hereby grant permission to the Laguna Department of Education-Partners for Success to Photograph, Video Record, Audio Record me and use the images, my name and sounds obtained for print, radio, electronic media, websites or video broadcasts anywhere throughout the United States and to edit such media for the sole purpose of promoting Partners for Success.

I hereby attest that I have read and agree to the above statement.
Signature*

Clear
Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email Address
username@company.com
If you are under the age of 18 years of age, the signature of Parent/Guardian is also
required:
Parent/Guardian Name
Parent/Guardian Signature

Clear
Date

MonthDayYear

Tribal Background Check

Youth Employment ONLY (click "Next" if Not Applicable)
I give permission for the Laguna Department of Education to proceed with the Pueblo of Laguna background check for pre-employment purposes for the Partners for Success Youth Employment Program.
Parent/Guardian Signature

Clear
Date

MonthDayYear
18 and older, the signature of Parent/Guardian is not required.
Youth Signature

Clear
Date

MonthDayYear

Release of Background Information

Youth Employment ONLY (click "Next" if Not Applicable)
I give permission for the Laguna Department of Education - Human Resources department to Release Background Information, which will include Quest Diagnostics Drug Test and POL Tribal Police Background Check results regarding myself or my child who will be employed with the Partners for Success Youth Employment Program to the Pueblo of Laguna - HR department or Laguna Rainbow Corp.
Parent/Guardian Signature

Clear
Date

MonthDayYear
18 and older, the signature of Parent/Guardian is not required.
Youth Signature

Clear
Date

MonthDayYear

Affidavit for PFS Youth Employment

Youth Employment ONLY • This form is for those 18 and older only (click "Submit" if Not Applicable)
I, First Name Last Name , being duly sworn, hereby deposes and says;

1. I am over the age of 18 and I am a resident and tribal member of the
Pueblo of Laguna, New Mexico. I have personal knowledge of the facts
herein, if called as a witness, could testify completely thereto.

2. I do not receive financial support, social security, nor personal income to
the best of my knowledge.

I declare that, to the best of my knowledge and belief, the information is true,
correct and complete.

Executed this DAY OF MONTH day of MONTH , 2022.
Signature

Clear
Should be Empty:

Partners For Success

Applicant Information

Education History

Barriers/Offender Barriers/At Risk

Work History

Certification of Applicant:

Required Documents

Identification: Age

Proof of Residence

Verification of Indian Blood

Selective Service Registration

Social Security

CERTIFICATION

Personal Statement for Services

W-9

Media Release

Tribal Background Check

Release of Background Information

Affidavit for PFS Youth Employment