GAP & PACE Application Form

Name*

First Middle Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical address is different from mailing address?*

Yes

Physical Address*

Street Address Address Line 2 City State ZIP Code

County of Residence*

NCC Student ID

Social Security Number

Date of Birth*

Gender

Female

Male

How did you hear about our program?

Phone*

Email*

Ethnicity: Hispanic/Latino

Yes

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Native Language (If other than English)

U.S. Citizen*

Yes

Authorized to work in the U.S.*

Yes

Registered for selective service (male, 18+)

Yes

U.S. Veteran (current/former)*

Yes

Spouse / Child of a veteran*

Yes

Household Information

Legal Marriage Status*

Can anyone claim you as a dependent on their tax return?*

Yes

Number of persons in household*

Please enter a number from 0 to 20.

Number of children can you legally claim on your tax return*

Please enter a number from 0 to 20.

Income Information

List ALL sources of monthly gross income received from ALL household family members related by blood, marriage or adoption.

Income*

SS Disability

SS Old Age/Survivor

FIP

Child Support

Retirement/Pension

Workman's Compensation

Unemployment Benefits

Food Stamps

Other - Please Specify

Currently participating in or recently applied for any of the following programs

AARP

American Indian Council

Promise Jobs

Proteus

Veteran's Administration

Vocational Rehabilitation

Workforce Investment Opportunity Act

Employment Status

Current Employment Status*

Unemployment Status*

Work History (include volunteer work, part-time, and self-employment)

Employer Name (1)

Job Title (1)

Hours / Week (1)

Wage / Hour (1)

Start Date (1)

End Date (1)

Job Duties (1)

Reason for Leaving (1)

Employer Name (2)

Job Title (2)

Hours / Week (2)

Wage / Hour (2)

Start Date (2)

End Date (2)

Job Duties (2)

Reason for Leaving (2)

Employer Name (3)

Job Title (3)

Hours / Week (3)

Wage / Hour (3)

Start Date (3)

End Date (3)

Job Duties (3)

Reason for Leaving (3)

Educational Information

Plan of Study*

Plan to work in Iowa after training*

Highest level of education completed*

Currently enrolled in school*

Yes

Area of Study*

Name of School*

Barrier Information

Have you EVER been charged, arrested, or convicted of a misdemeanor or felony? If yes, describe the legal problem (include any pending legal actions and/or court orders)*

Please check all that apply*

Signatures

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 programs. 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. Also, I authorize the use of my Social Security number as an identifier for program administrative purposes.

Applicant Signature (please type full name)*

Date*

It is the policy of Northwest Iowa Community College not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, creed, religion, and actual or potential family, parental or marital status.

If you have questions or complaints related to compliance with this policy, please contact one of the Equity Coordinators at Northwest Iowa Community College, 603 West Park Street, Sheldon, Iowa, room D403b or room A101D, email equity@nwicc.edu, phone number 712-324-5061, extension 113 or extension 137; or the Director of the Office for Civil Rights, U.S. Department of Education, Cesar E. Chavez Memorial Building, 1244 Speer Boulevard, Suite 310, Denver, CO 80204-3582, Telephone: (303) 844-5695 FAX: (303) 844-4303, TDD 800-877-8339 Email: OCR.Denver@ed.gov.

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GAP & PACE Application Form

Household Information

Income Information

Employment Status

Work History (include volunteer work, part-time, and self-employment)

Educational Information

Barrier Information

Signatures

Tuition & Financial Aid

NCC Campus

Academics

Admissions