Work-Based Learning Application
(Apprenticeships and On-The-Job-Training) Please fill out the information below and look for a follow-up email about the next steps!
Contact Information
Name
First Name
Last Name
Social Security Number (Last 4 SSN Number)
Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Please Select
Pinellas
Hillsborough
Pasco
Hernando
Manatee
Polk
Other
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Demographic Information
Date of Birth
-
Month
-
Day
Year
Date
What is your current age?
What is your gender?
Please Select
Male
Female
Do not self identify
Please select your citizenship status
Please Select
I am a U.S. citizen
I am not a U.S. citizen
I am a permanent resident
Selective Service
Please Select
Yes
No
Not Applicable (females only)
Are you married?
Please Select
Married
Single
Are you an English language learner?
Please Select
Yes
No
Are you a veteran?
Please Select
Yes
No
Are you the spouse of a member of the armed forces
Please Select
Yes
No
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Disabilities and Related Conditions
Please select which disability status applies to you.
I do not have a disability
Physical/chronic health condition
Physical/mobility impairment
Mental/psychiatric disability
Vision-related disability
Hearing related disability
Learning disability
Cognitive disability
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Low Income Eligibility
Please select which foster home situation applies to you
Please Select
Currently in foster care
Aged out of foster care
Never in foster care
New Option
Are you an ex-offender or have you been arrested or convicted of a crime?
Please Select
Yes
No
Have you or an immediate family member received TANF or cash assistance within the last 6 months?
Please Select
Yes
No
Have you or an immediate family member received SSI (Supplemental Security Income) within the last 6 months?
Please Select
Yes
No
Have you personally received Supplemental Security Disability Insurance within the last 6 months?
Please Select
Yes
No
Have you or a family member received food stamps (SNAP) within the last 6 months?
Please Select
Yes
No
Are you homeless?
Please Select
Yes
No
What is your household monthly income?
What was your TOTAL household income for the previous 6 months? (This will be verified, so please be as accurate as you can)
How many family members live in your household? (Include yourself)
Have you found employment with your current skills or work experience that leads to self-sufficiency?
Please Select
Yes
No
Are you unlikely to return to a job at self-sufficient wage?
Please Select
Yes
No
Are you pregnant or parenting and between the ages of 16-24?
Please Select
Yes
No
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Employment History
Are you Currently Working?
Please Select
Yes
No
How far are you willing to travel for work?
Up to 5 miles
Up to 10 miles
Further than 10 miles
What shifts are you willing to work?
Day
Evening/Swing
Night/Graveyard
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Education History
Please select which training program you are interested in
Please Select
OJT (On-the-Job Training) ask for a list of available options
Independent Electrical Apprenticeship
Learning Alliance
Net Synergy Apprenticeship
UMA (Ultimate Medical Academy)
SPC Get There Faster
SPEC Open Door Grant
SPC Other
Other Apprenticeship (not listed)
Are you currently enrolled in school?
Please Select
Yes
No
Did you drop out of high school and not return?
Please Select
Yes
No
Are you currently attending an adult education center or online school? (Check yes if you are not at a public school but still earning your GED or High School Diploma)
Please Select
Yes
No
What is the highest grade you've completed? (0-12)
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
Please select what you've earned
None
GED
High School Diploma
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
Other
Please list any additional licenses or certificates you have
What Pell Grant situation applies to you?
Please Select
I have not applied for Pell
I have applied for Pell and am waiting
I have been awarded the Pell grant
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Dislocated Worker Eligibility
Were you laid off/terminated from your last job?
Please Select
Yes
No
Are you long term unemployed? (27 or more consecutive weeks)?
Please Select
Yes
No
Are you currently receiving Ra/unemployment benefits?
Please Select
I am a claimant
I have exhausted my unemployment
I have neither claimed nor exhausted my unemployment
Have you applied for Ra/unemployment but are waiting for it to start?
Please Select
Yes
No
What is the date of your last Ra/unemployment payment?
-
Month
-
Day
Year
Date
Have you worked or earned wages since exhausting your Ra/unemployment?
Please Select
Yes
No
Have you been able to find employment with current skills that leads to self sufficiency?
Please Select
Yes
No
Are you a self employed individual who has lost your employment contract or business earnings due to the economic downturn and has been unable to find employment or replace your business earnings?
Please Select
Yes
No
Are you an individual who has been providing unpaid services to a family member in the house while being dependent on income from another family member?
Please Select
Yes
No
Are you no longer supported by the income of the family member and are facing difficulty in obtaining or upgrading employment?
Please Select
Yes
No
Are you a recently separated service member with a honorable discharge who has received a notice of separation within the past 48 months who is unlikely to return to a previous industry or occupation?
Please Select
Yes
No
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MUST READ BEFORE SUBMISSION
After submitting the application, you will receive an email within 24 hours explaining the following steps that take place in Employ Florida, a statewide job and training assistance website. Select "I understand" next to each step that you will complete after submitting this application.
Make an Employ Florida registration at employflorida.com
I understand
Upload a picture of your ID and Social Security Card in Employ Florida. (Or come to our location to make copies)
I understand
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