IITNJ Financial Assistance Intake Form

Do you have a criminal background? *This will not affect eligibility**

YesNo

If Yes, Please provide SBI Number #

If Yes, Please provide Inmate Number #

What type of position do you desire? (Check all that apply)

Full TimePart TimeBothNot Seeking Employment at this time

Which employment duration do you desire? (Check all that apply)

Regular(150 Days+)Temporary (150 days or less)Both

Are you willing to work any shift?

YesNo

If you check no, which shifts do you prefer? (check all your preferences)

What's the minimum salary do you desire to make?

per hour

Date Available to Work

Date

What is your objective for employment?

(To get a better paying job, to transfer to a different job field, etc...)

Desired Job Title 1

Desired Job Title 2

Desired Job Title 3

Desired Job Title 4

Desired Job Title 5

Desired Employer 1

Desired Employer 2

Desired Employer 3

How many miles is acceptable to work from where you live?

Enter the Zip You would be commuting from

Job Position *

Employer *

Street *

City *

State *

Start Date *

Date

End Date *

Date

Wage ($)*

Wage Rate*

hour, bi-week, month etc.

Reason for Leaving*

What were you job duties and responsibilities?

If you wish to provide additional work history, inform Enrollment Specialist at the time of your appointment.

Additional Skills

Professional Associations

Certificate/License

Issued By

Date Issued

Date

Street Address

Street Address Line 2

State / Province

Country

Education/course of study

Degree

School

School address

Street Address Line 2

State / Province

Country

Do you have a license*

YesNo

If you choose yes above, enter state:

Street Address

Street Address Line 2

State / Province

License Type

I have access to

Transportation (Select all that apply)

I own a vehicleI have insurance

Endorsements

I attest that the information provided is true and accurate. Any misrepresentation may be grounds for termination from program(s).
I also understand that being eligible for services and/or training does not necessarily entitle me to service/training.

Applicant Signature*

Today's Date*

Date

Parent/Guardian Signature

Today's Date

Date

Please upload a picture of your Birth Certificate.*

Please upload a picture of your Social Security Card*

Please upload a State ID*

This can be: : This can be a State Driver's License/ID or an Unexpired Passport.

Please upload your High School Diploma or Equivalent*

This can be your High School Diploma or Transcripts, GED, or College Degree.

Please upload a Proof of Address*

This must be a piece of mail that reflects the same address that is on your State ID.

Please upload a picture of your Individual & Family Income

This can be: : Last Pay Stub and/or W-2, If married, Spouse's last pay stub and/or W-2, Alimony Agreement, Child Support, Disability Benefits, Pension Statement, If Self Employed, Quarterly Estimated Tax Social Security Award Letter, Workers Compensation

Public Assistance / Food Stamps: If you are receiving TANF or GA, you will be required to provide a referral for training from your case manager

Ideal Institute of Technology Financial Assistance Application Form

Current Address

Migrant Seasonal Farmworker

Public Assistance

Military Section

Offender Status

Employment Preferences

Work History

Certificate/Special Licenses

Drivers License