| Today's Date: |
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| Date of Birth: |
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| Name (Last, First, Middle Initial): |
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| Address: |
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| Address (cont'd): |
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| City: |
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| State: |
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| Zip Code: |
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| County: |
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| Email Address: |
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| Phone (Home, Work, & Cell): |
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| Gender (Male or Female):: |
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| US Citizen (Yes, No but eligible for work, or No, inelible for work): |
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| Are you a veteran? (Yes or No): |
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| Are you registered with Selective Service? (Yes or No): |
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| Do you have a disability? (Yes or No): |
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| Do you consider yourself Latino or of Hispanic origin? (Yes or No) You do not have to answer: |
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| Do you consider yourself (Select one or more of the following---You do not have to answer): American Indian or Alaskan Native, Asian, Black or African American, Hawaiian or Other Pacific Islander, White, Other (write in): |
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What is the highest grade or year of regular school that you have completed? (Use key below):
00-12=Number of elementary/secondary years
13-15=Number of college or full-time technical or vocational years completed
16=Bachelors Degree
17=Education beyond Bachelors Degree
87=Attained HS Diploma
88=GED or Equivalent
89=Certificate of Attendance/Completion
90=Post-Secondary Degree/Equivalent
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| Are you employed? (Yes or No): |
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| Are you receiving any of the following: Unemployment Benfits, TANF, Food Stamps: |
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| Are you a current WIA participant? (Yes or No): |
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| Current or Most Recent Employer: |
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| Job Title: |
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| Starting Date: |
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| Ending Date: |
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| Pay Rate (Hourly): |
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| Hours worked per week: |
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| Previous Employer:: |
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| Job Title: |
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| Starting Date: |
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| Ending Date: |
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| Pay Rate (Hourly): |
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| Hours worked per week: |
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| What course would you like to apply for?: |
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| What is the training provider's name and location?: |
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| Are you eligible for a Pell Grant? (Yes or No): |
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| Total Cost of Course: |
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| Scholarship Amount (80% of Total Cost): |
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| Is this an Open Entry/Open Exit Program?: |
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| Program Start Date:: |
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| Program End Date:: |
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| Are you a previous e-magnolia participant? If so, how many times have you been enrolled? |
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By submitting this application, I understand that my application will be reviewed and is pending approval by the WOLIP State Coordinator. I understand that this WOLIP scholarship is provided to help me qualify for and obtain a job. I agree to seriously pursue this training and understand that failure to make satisfactory progress in training may result in withdrawal or suspension of this program. I agree to cooperate with the State Coordinator and the training provider during my training program and to immediately notify the State Coordinator of any change in my status, including any absences from training. I understand that this scholarship is limited to the appropriate approved training costs and that any additional costs or increases in cost will not be covered by this scholarship. I understand that I am responsible for 1/5 of the cost of the training program. If equipment costs exceed $200, the 1/5 participant contribution will be waived (Validated prior to training by Training Provider). When hired, I agree to provide employer and wage information to the WJC or State Coordinator and to cooperate in all required follow-up activities.
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