Northern Nevada
Member
Assistance
Program
Navigate. Empower. Unite.
Preparing Apprentices with
Supportive Services (PASS)
Program Assistance Request
There is a cap of $300 per applicant.
Apprentices are eligible for two
calendar years from their date of
initiation but may only apply once.
Date of Request:
-
Month
-
Day
Year
Date
Student Information
Name
First Name
Middle Initial
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email
example@example.com
Birth Year
Gender
Have you previously received funding from this program?
Yes
No
Date:
Amount:
Highest level of education completed?
Do you have a valid Nevada driver's license?
Year of High School graduation?
High School
City
Check all that apply:
Are you a veteran?
If yes, date of discharge?
Occupational specialty?
Ever been involved in juvenile rehabilitation?
Been formerly incarcerated?
Been in the foster care system?
Any previous occupational/trade training?
Ethnic Origin (check all that apply - you may leave this section blank):
Black/African American
Latino/Hispanic Native
Asian Hawaiian/Pacific Islander
Caucasian
American Indian/Alaskan Native
Prefer not to disclose
What, if any, barriers are you facing? (check all that apply)
Currently Un-housed
Lack of Reliable Child Care
Limited English Proficiency
Disability/Special Needs
Substance Abuse
Limited Math Skills
No Dependable Transportation
No High School Diploma or GED
Lack of funds for equipment, boots, books, etc
Other
APPLICATION #
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Trade Information
Enrolled in which Apprenticeship Program?
Apprenticeship Program Selection
Bricklayers BAC13
Construction Craft Laborers LIUNA169
Electricians IBEW401
Elevator Constructors IUEC8
Heat and Frost Insulators Local 16
Iron workers IW118
Nevada Energy IBEW1245
Painters/Allied Trades IUPAT567
Operating Engineers OE3
Plumbers/Pipefitters UA350
Plasterers/Cement Masons OPCMIA797
Sheet Metal SMART26
Other:
Union Affiliation:
Program contact name
Email Address
example@example.com
Apprentice Year
Date of Initiation
-
Month
-
Day
Year
Date
Member #
Apprenticeship Program Representative Approval
Name
Signature
Phone Number
Program Expected Start Date:
-
Month
-
Day
Year
Date
List out the cost of boots, equipment/tools, supplies, and books for which you are requesting financial assistance for program completion:
Cost:
Clothes/Boots Cost (Purpose Built)
Tools Cost (Fasteners Inc., NO POWER TOOLS)
Cost of Books
Other Assistance requested (explain below)
Total Request
Detailed explanation and costs of "other" assistance (Dues Payments by Special Circumstances Only):
2
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