Download Application for Referral

Application
Positive Pathways Program (P3)
4112 S. Main Street, Los Angeles, CA 90037
Tel (323) 432-3955
Fax (323) 432-3995
PVJOBS P3 provides academic coaching, career exploration and workforce development services to qualifying
participants.
Personal Information
__________________________
First Name
_____
________________________
Last Name
M. I.
____________
Date of Birth
________ -_______-_____
Social Security Number
_______________________________________________________________
___________________________ ____________
_________________________
Present Address
City
Zip Code
_______________________________________________________________
___________________________ ____________
_________________________
Alternate Address
City
Zip Code
State
State
(______) ________-______________
(______) ________-______________
_______________________________________________________________
Phone Number
Alternate phone Number
Email:
Gender:
Male
Female
Ethnicity:
Asian/Pacific Islander
Driver’s License/Identification Card
Selective Service Registration:
Black/African American
Yes
No
Hispanic/Latino
Middle Eastern
Yes
No
Native American
N/A
Caucasian
Issue State:___________ Number:______________________________
________________________________________________________________________________________________________________________
Education
High School Graduate? Yes
CHECK ALL THAT APPLY
No
Highest Education Level:
____th grade
Certificates
Trade School
HS Diploma
GED
College/University
Jr. College
Graduate
U.S. Military or Naval Service (if applicable) _________________________________________ Rank ________________________________________
Goal Statements
Educational Goal:______________________________________________________________________________
Career Goal:__________________________________________________________________________________________________________________________
Eligibility Factors Must meet all four criteria to be eligible for program
Applicant Age between 16-24




Driver’s License
Birth Certificate
Identification Card
US Passport
Involvement with Justice system (within 1 year)


Release record
 Record of arrest
Probation department
 Self certification
documentation
Arrest date: _____________
Release Date:______________
Living within Service Area ( Central or East L.A)
 Driver’s License, utility bill
 Legal document with address
PLEASE READ CAREFULLY

Involvement with Juvenile Justice system


Release record
 Record of arrest
Probation department
 Self certification
documentation
Arrest date: _____________
Release Date:______________
I certify that the information I have provided on this form is true and complete to the best of my knowledge.
Applicant Signature: ___________________________________________________ Date: ___________________________________
If under 18, must be signed by parent or guardian: __________________________ Date: __________________________________
TO BE COMPLETED BY REFERRING AGENCY
Client Service History and DOR Pre-Qualification
What medications is client taking? ____________________________________________________________________
Was client ever in special education or diagnosed with a learning disability or attention deficit disorder?  Yes  No
Does client have a psychiatric impairment, a medical impairment, or learning difficulty?
 Yes  No
Does client have a resume?
 Yes  No If yes, is the resume included with this application?  Yes  No
Was a standardized assessment done?  Yes  No If yes, which test was administered? _______________________
Was a supportive service assessment done?  Yes  No
If yes, what supportive services will customer need? _______________________________________________________
_________________________________________________________________________________________________
What supportive services are you providing? ____________________________________________________________
Is client or client’s children receiving AFDC?  Yes  No
Client Service
Union Trade Specific Requirements:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Is Candidate Fluent in English?
Yes
No Is Candidate Proficient in Math and Reading?
Did candidate complete 9th Grade Math?
Does candidate have Transcripts demonstrating 2 semesters of high school Algebra or 1 semester of college Algebra?
Was candidate informed that the employer may require a drug test prior to hire?
Did candidate sign a release of information statement?
At-Risk Factors
Please check all that apply. PVJOBS seeks to provide opportunities to those at greatest risk. This information is kept in strict confidence. Bullet
points are acceptable documentation to certify/ verify at-risk factors. Collected documentation must be saved in client’s files. Note: Self certification
should be used as a last resort when no other documentation is available.
Household income below 50% of median
 Income documentation for last 6 months (pay stubs, UIB claims, cash
award letters) and family size verification (birth certificates)
 Income Tax Return
Homeless
 Letter from shelter or person providing temporary living space
 Self certification form
Welfare recipient
 Gain or DPSS Certification form.
 DPSS Notice of Action
Single parent
 Birth certificate of
 DPSS Notice Of Action
dependent children
 DPSS Certification form
 Income tax return
 Self certification
Involvement with justice system
 Release record
 Record of arrest
 Probation department
 Self certification
documentation
Unemployed
 Layoff notice
 UIB printout
 Self Certification Form
Did not complete High School
 Self certification
History of Substance Abuse
 Letter from a drug intervention program
 Release record
 Record of arrest
 Probation documentation
 Self certification
Certification
I certify that the at-risk factors above apply to this candidate and are accurate and reliable.
Signature: __________________________________________ Date: __________________________________________________
Print Name: ________________________________________
Job Title: _______________________________________________
Agency:____________________________________ Phone:________________________________________
Internal Office Use Only
111209 RefForm
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111209 RefForm
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