Career Pathways Program Application

Career Pathways Program Application
TODAY'S DATE*

MonthDayYear
WHICH PROGRAM ARE YOU APPLYING FOR?*
NAME*

First NameLast Name
DATE OF BIRTH*

MonthDayYear
Date
EMAIL*
example@example.com
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
PHONE*
ALTERNATE PHONE
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE
RELATIONSHIP (TO EMERGENCY CONTACT)
GENDER*
RACE
ARE YOU A FEMALE HEAD OF HOUSEHOLD?*

YesNo
ETHNICITY

Of Spanish/Hispanic/Latino OriginNot of Spanish/Hispanic/Latino Origin
Have you ever been convicted of a misdemeanor (this includes without limitation, pleading guilty, pleading no contest, or having a finding of guilty?*

YesNo
Have you ever been convicted of a felony? (This includes without limitation, pleading guilty, pleading no contest, or having a finding of guilty?*

YesNo
If you checked “Yes”, please list details (What was the offense? City/State? Dates?)
How did you hear about the program?*
EDUCATIONAL BACKGROUND
HIGHEST GRADE LEVEL COMPLETED:*

High SchoolVocational TrainingCollegeOther
NAME OF LAST SCHOOL/TRAINING ATTENDED
DO YOU HAVE A DISABILITY?*

YesNo
*If Yes Describe
Do you receive public benefits, including food stamps, subsidized housing, child care subsidies, WIC, Medicaid, SCHIP, unemployment, etc.?*

YesNo
ARE YOU A VETERAN?*

YesNo
EMPLOYMENT STATUS*

EmployedNot Employed
Work History (LIST MOST RECENT EMPLOYERS FIRST)

	Dates (From-To)	Employer Name	Employer Address	Phone No.	Salary (Start-End)	Reason for Leaving
Employer 1
Employer 2
Employer 3

Source of Income*

A. EmploymentB. UnemploymentC. Social SecurityD. TANFE. GAF. SSI/SSDG. PensionH. No IncomeI. OtherJ. Zero IncomeK. Refused – Only used for programs that do NOT require income verification
Income Amount*
Income Eligibility Period*

A. WeeklyB. Bi-WeeklyC. MonthlyD. AnnuallyE. 13 WeeksF. 3 MonthsG. 6 Months
List Your Household Members
Member 1

First NameLast Name
Member 2

First NameLast Name
Member 3

First NameLast Name
Member 4

First NameLast Name
Member 5

First NameLast Name
Member 6

First NameLast Name
Ethinicity:

Black/African American, Asian, Native Hawaiian/Pacific Islander, Native American/Native Alaskan, Hispanic or Latin, White, Other, Multi-race

Education:

A. 0-8, B. 9-12 C. HS Grad/GED D. 12+ E. 2-4 yr Grad College

Health Insurance:

A. Medicaid B. Medicare C. Private D. Self-Ins E. None F. Unknown

Income Period:

A. Weekly, B. Bi Weekly, C. Monthly, D. Annually, E. 13 Weeks, F. 3 Months, G. 6 Months

Source of Income:

A.Employment, B. Unempoyment, C. Social Security, D. TANF, E. Governtment Assistrance, F. SSI/SSD, G. Pension, H. No Income, I. Other, J. Zero Income, K. Refused- Only used for programs that do NOT require income Verification

Use codes from above ONLY:

	DOB	Gender	Disabled	Ethnicity	Edu	Veteran	Health Ins	Income Period	Source	Income Amt
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6

Zero Income Self-Declaration Worksheet

Please state the amount of your monthly expenses. (CHECK ALL THAT APPLY)

	Monthly Amount	Given to you	Paid Directly by Creditor
Rent/Mortgage/Taxes
Food
Gas/Electric
Water
Phone
Car Payment/Insurance
Cable/Internet
Personal Expenses
Bulk Fuel
Other Expenses

DOES YOUR HOUSEHOLD RECEIVE ANY OF THE FOLLOWING?
Food Stamps*

YesNo
If you answered yes, enter the monthly amount below:
Rental Assistance such as subsidized housing*

YesNo
If you answered yes, enter the monthly amount below:
Utility Allowance?*

YesNo
If you answered yes, enter the monthly amount below:
Briefly explain how you maintained your household bills and expenses within the past 90 days.

If you are receiving assistance with paying your bills and / or expenses from a non-household member, please list their name, address and phone number below. If one or more person is paying expenses, have him/her submit a separate statement.

	Name	Address	Phone
1.
2.
3.

I understand that by signing this form, I authorize the Ohio Department of Development, Office of Community Services or its designated representatives, access to public assistance, social security, employment information or other records needed to verify any statements I have made.

I declare under penalty of perjury that the information submitted on this worksheet is true and correct.
Customer Signature*

Clear
Date *

MonthDayYear
Date
Staff Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Career Pathways Program Application

EDUCATIONAL BACKGROUND

Work History (LIST MOST RECENT EMPLOYERS FIRST)

List Your Household Members

Zero Income Self-Declaration Worksheet