GAP, PACE, or Associated Programs Application Listen "*" indicates required fields Name * Required First Middle Last Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code You must be an Iowa resident to participate.Cell Phone Number * RequiredTexting OK * Required Yes No Alternate Phone NumberEmail * Required Birth Date * Required Month Day Year Gender Male Female Prefer not to answer What program or degree are you interested in completing? * Required Program Start (Month & Year) * Required Are you eligible to work in the United States? * Required Yes No Note: Proof of work eligibility may be required, such as a copy of a valid Work Authorization Card.Which of the following best describes your current employment status? * Required Check no more than TWO. Working full-time (35 hours or more per week) Working part-time (less than 35 hours per week) Unemployed (I am looking for work) Dislocated Worker (I have been terminated or laid off because of plant closure or substantial layoff) I am not currently working or seeking employment Other Please describe. * Required Are you currently receiving SNAP food assistance ? * Required Yes No What is the total gross income from the last 3 months that supports your household? * RequiredNOTE: If the initial gross annual income appears to qualify you for funding, income documentation (W2, paystubs, tax returns, etc.) may be required to document final eligibility for GAP or PACE funding.Number of people in your household related by blood or by marriage. * RequiredInclude yourself in this count.I certify that the information I have provided on this application is true to the best of my knowledge. I am also aware that the information I have provided may be reviewed and verified, and that I may have to provide documents to support this information. I allow release of this information for documentation purposes. Further, I understand that this information will be used to determine my eligibility for the GAP/PACE Tuition Assistance Program. I am aware that I am subject to immediate termination and that I may be prosecuted for fraud and/or perjury if I am found ineligible after enrollment. I authorize the use of my Social Security Number as an identifier for program administrative purposes. I understand that completion of this application does not guarantee assistance from the GAP, PACE or associated programs.Signature (Please type full name) * Required Date * Required MM slash DD slash YYYY CAPTCHA
