Accelerating Opportunities (AO) (504) 278‐6229 www.nunez.edu Student Application Today’s Date ______________ Name First Middle Last Social Security Number Gender □ Female Date of Birth Street Address City □ Male Can we contact you via text message? / / □ Yes □ No Mailing Address (if different than street address) Home or Cell Phone Number State Zip Primary Email Another E‐mail or Phone Number to Reach you At Emergency Contact Name Emergency Contact Phone Number Voluntary Demographic Data Incumbent Worker Status TAA Eligibility/Dislocated Workers Are you currently employed? □ Yes □ No Ethnicity Are you Hispanic or Latino? □ Yes □ No If yes, when do you work? Are you eligible* for TAA Service (Trade Adjustment Assistance certified by DOL)? □ Yes □ No □ Unsure *You lost or may lose your job due to product or service sent to another country □ Morning □ Afternoon □ Evening Please select one or more of the following (Check all that apply): Employer’s name: Are you a dislocated worker? (laid off through no fault of your own) □ Yes □ No □ American Indian or Alaska Native □ Asian □ Black or African American □ Native Hawaiian or Other Pacific Islander □ White Job Title: Avg. hrs. worked per week: If yes, please list the employer: Hourly wage: ___________________ The Accelerating Opportunities Grant is funded by Jobs for the Future Legal Program of Study Education Do you currently attend school or an education program? Are you registered with Selective What pathways are you interested Service? (males only) in and when? □ Yes □ No Please select all that apply: □ Yes □ No Have you ever been convicted of Healthcare a crime? (Note this will NOT Field _____________________ exclude you from the program.) Have you taken the TABE test in the past six months? □ Yes □ No Business Technology □ Yes □ No Field _____________________ Have you ever attended Nunez or any LCTCS School? □ Yes □ No If yes, Industrial Technology □ Felony □ Misdemeanor □ Gross Misdemeanor Please list offense and year Field _____________________ Please list the colleges you have attended. □ Morning □ Afternoon □ Evening If you are in college, what is your status? □ Full Time (more than 12 credits) □ Part Time (less than 12 credits) How Did You Hear About Us? Military Status Are you: □ Activity Military □ A Veteran □ Not a Veteran □ An eligible spouse What is the highest level of education that you have completed? □ Website/Email □ Radio □ TV □ Newspaper □ Instructor □ Friend □ Newspaper □ Work □ Church or Community Organization □ Some high school – last grade completed: □ High School Diploma □ High School Equivalent (GED/ HiSET) □ Some college but no credential □ Any credential or certificate – Year Type □ Associate’s Degree (two year degree) □ Bachelor’s Degree (four year degree) □ Graduate or Professional Degree □ Other (Please Explain) Have you applied for AO before? □ Yes □ No Is English your first language? □ Yes □ No This information is being requested to determine eligibility of grant‐funded services. I know that state and federal privacy laws protect my records. If I have a question about anything on this form, or would like further explanation, I can discuss it with the program staff. I understand: ‐Why I am being asked this information. ‐I do not have to provide the information or consent designated on this form. However, if I do not, I may not be eligible for grant‐funded services. ‐Any information gathered will be kept confidential. I agree that the information I have provided is true and correct to the best of my knowledge and ability. Signature Date Nunez Community College does not discriminate on the basis of race, color, gender, religion, national origin, age or disability. The Accelerating Opportunities Grant is funded by Jobs for the Future Accelerating Opportunities Short Answer Application Name Why do you think you would be successful in this program? What are your short and long term career goals? What do you hope to gain from this program? The Accelerating Opportunities Grant is funded by Jobs for the Future