WA Worker Retraining Scholarship

Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Social Security Number*

The WA Retraining Worker program requires your SSN. See SSN authorization for intended use at the bottom of this page.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

example@example.com

Select the Bootcamps you would like to attend*

Select the most applicable option:*

Dislocated worker, claiming UI benefits: Upload eServices portal printout or most recent UI check stub.Dislocated worker, exhausted benefits: Upload eServices portal printout showing exhausted UI benefits within the past 48 months.Dislocated worker, received notice of lay-off: Upload lay-off notice from employer and current WA state UI Monetary Determination form. Student must provide acceptable documentation when they start claiming UI.Vulnerable worker on expanded eligibility policy: Upload evidence occupation “not in demand”, self-attestation and/or employer statement. Check https://esd.wa.gov/labormarketinfo/learn-about-an-occupation#/searchStop Gap Employment: Upload self-sufficiency calculator, recent pay stub showing income at or below 70% of Washington’s Median Family Income, or signed Worker Retraining Self- Attestation. Check https://www.dshs.wa.gov/esa/eligibility-z-manual-ea-z/state-median-income-chartDisplaced homemaker: Upload signed attestation by eligible student supported by a copy of WA state legal document, such as divorce decree, legal separation, death certificate. If employed, proof that net earned income (pay stub or tax return) is at or below 70% of Washington’s Median Family Income. Check https://www.dshs.wa.gov/esa/eligibility-z-manual-ea-z/state-median-income-chartFormerly self-employed: Upload attestation by eligible students, most recent tax return indicating self- employment, and proof of economic condition or natural disaster that resulted in unemployment.Active-Duty Military Member: Upload official notice of separation.Unemployed Veteran: Upload DD214 (discharge papers) showing a separation date within the past 48 months and a WA state-issued identification card.

Eligibility Documentation Upload*

View full eligibility requirements at https://www.sbctc.edu/resources/documents/colleges-staff/grants/wrt-pcsc/student-information-and-attestation.pdf

Student Attestation:

I hereby attest that I meet the eligibility criteria checked in question one (above) and wish to apply for WRT funds to assist me with tuition at Nucamp. I have provided the most current documentation available to substantiate my eligibility. I understand that Worker Retraining funds will pay for tuition only.

Student Acknowledgement of Receipt (SAR):

I have been provided with information about the program completion and placement rates of the program of study and the career or occupational outlook for this program of study in the local labor market.

Signature*

Date*

Date

The Washington State Board for Community and Technical Colleges (SBCTC) pursuant to RCW 28B.50.090 authorizes this organization to ask you to provide your social security number. The number will be used for keeping records, research on students in general, and summary reporting. Your number also will be provided to SBCTC. SBCTC gathers information about students and programs to meet state reporting requirements. It also helps to plan, research and develop programs. This information helps to support the progress of students and their success in the workplace and other educational programs. When conducting research, your social security number will only be disclosed in a manner that does not permit personal identification. Your social security number will never be used to report personal information. By providing your social security number, you are consenting to these uses as identified. Provision of your social security number and consent to its use is not required and if you choose not to do so, you will not be denied any right, benefit, or privilege provided by law. You may revoke your consent for the use of your social security number at any time.

	Yes	No
Are you formerly self-employed, and no longer have work because of local economic conditions?
Are you formerly self-employed, and no longer have work because of a natural disaster?
Are you a displaced homemaker?
Are you currently unemployed?
Are you currently employed, but have a net income of less than 70% of Washington’s Median Family Income (displaced homemakers and stop-gap employment categories only)
Are you currently employed, but the position is temporary in nature and only intended to support you as you complete training? Upon completion of your training program you intend to end this job for a position in line with your training program.
Have you earned 45 college-level quarter credits (30 semester credits) and a credential?
Have the minimum qualifications for your current position changed and training is necessary to maintain employment in your current position?

WA Worker Retraining Scholarship

Your Information

Eligibility Selection

Student Attestation:

Student Acknowledgement of Receipt (SAR):

Signature and Submission

Self-Attestation Form

Self-Attestation Questions:

Student Statement:

Self-Attestation Statement: