Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Page 2 of 2 111209 RefForm Page 2 of 2