ETA-652 Primary Applicant Form

Date: 11/21/2006

Primary Applicant Form

OA Counselor:

Interview Date:

Application Type:

OAC Address:

Phone:

Ssn:

Student ID:

Date of Birth:

Name:

Sample:

Place of Birth:

Race:

Center:
Sex:

Address:

Phone:

Primary Contact:

Phone:

Alternate Contact:

Phone:

Legal Resident:

U.S. Citizen:

GED/High School Diploma:

Highest Grade Completed:

Currently Employed:

Previously Employed:

Family Status:

Number of Months Out of School:

Est. Annual Income:

Num. Dependents:

Number of Weeks Unemployed:
Allotment Eligibility:
Approved

Alien Regis Exp Dt:

Earnings per Hour:

Num. in Family:

Marital Status:

Review

Alien Regis No:

Prior Military:

Dep. Children:

Public Assist:
Bilingual Program Req:

Basic Skills Deficient:
Parent:

Child Care:

JCC Day Care Program:
Prior Conviction:

School Dropout:

Homeless Runaway or Foster Child:

Requires Additional Education, Vocational Training or Career Counseling:

Remarks:

Previous Enrollment Date:

Separation Date:

Center where Separated:

Destination of Applicant after Separation:
Reason(s) for Termination:
Reason(s) for Reapplying:

OMB Expiration Date 02/28/07

ETA 652 (REV 5/98)
Page 1 of 3

Date: 11/21/2006

Primary Applicant Form

APPLICANT COMMITMENT STATEMENT

I understand that entrance into Job Corps is a privilege, and that only those individuals who qualify and show commitment will be
accepted. The Job Corps program is a scholarship to attend a training program to enhance basic work skills that lead to quality
employment with advancement opportunities.
Benefits:
Job Corps provides a safe, drug-free living environment where I can attain:
Academic skills that I need to succeed in the work place. (GED, High School Diploma, Technical
Academic Education:
Training, College Preparation)
Vocational Training:
Social Skills:
Placement:

Occupational skills that I will need to succeed in today's competitive job market.
Life skills that I will need to get along well in the work place and in everyday life.
Job search skills and assistance in finding a job when I complete my training.

Initials

EXPECTATIONS:
1. I understand that violence, drug or alcohol use and sexual harrassment are not tolerated at Job Corps.
2. I understand that I must be drug-free upon entry and that I will remain drug-free while enrolled. I also understand that I will be
tested for drugs upon arriving at center.
3. I understand that I will be living in multi-cultural environment and sharing a dormitory room with other students.
4. I understand that I will be responsible for cleaning my living area and sharing responsibility with others students to maintain
a safe environment.
5. I understand that if I have problems on center I will contact my Center Counselor or Admissions Counselor to work out the problems.
6. I understand that I will be given an orientation to the center rules and regulations, and that I must abide by these policies to remain
in the program.
7. I understand that in order to obtain the benefits that Job Corps has to offer, I must attend classes and complete the program.
8. I understand that I will be on a 30-day probationary period and failure to successfully perform during that period may result in my
termination from Job Corps.
I certify that my Admissions Counselor has discussed the benefits and expectations of the Job Corps program with me. If I am accepted
to Job Corps, I agree that I will accept these conditions and commit to fully participate in the program.

Initials

OMB Expiration Date 02/28/07

ETA 652 (REV 5/98)

Page 2 of 3

Date: 11/21/2006

Primary Applicant Form

JOB CORPS CONSENT RECORD
The admissions counselor is to read each item on this consent form to the applicant and parent/guardian, if applicable, ensure that
he/she (they) understand(s) it, and have the applicant and parent guardian, if applicable, sign the form.
I (we), the undersigned, certify that all information on the application forms is accurate.
I (we) consent to the enrollment of the above-named individual into Job Corps.
I (we) further understand that any false statement or dishonest answers will be grounds for dismissal of the above named
individual and may be punishable by law.
I understand that, if I am required to be registered with the Selective Services System, I am authorizing Selective Services
to register me at the age of 18. I further understand that if I am already registered, the automatic registration process will not
register me again.
I (we) authorize all routine and customary physical examinations, dental work, surgical and other treatment as required by
the Job Corps regulations, as well as the collection of information such as education and medical records.
I (we) authorize release of medical information to Job Corps Staff with a need for that information and to the local and/or
state health department when required by the law.
I (we) have been provided with a personal copy of Job Corps Privacy Act statement. I (we) have read the statement and
understand its contents.
I (we) have been provided information about Job Corps, life on a Job Corps center, vocational offerings and
job outlook information. I (we) have been told what Job Corps expects of me as a student. All of my (our) questions have
been answered.
I (we) understand that I (we) are responsible for keeping the Job Corps center in which my son/daughter is enrolled
informed of any address changes.
I (we) authorize Job Corps to gather information about my employment after participating in Job Corps training.

Signed:

Applicant

Date

Parent/Guardian, if applicable.

Date

JOB CORPS READMISSION INFORMATION

READMISSION AGREEMENT
I hereby apply for readmission to Job Corps. I have never before been readmitted to Job Corps. To the best of my knowledge there has
been no significant change in my physical condition since I left Job Corps. If my application for readmission is approved, I authorize
Job Corps to withhold an amount from my readjustment allowance which will repay the government for the cost of transportation
provided for my readmission.
Signature of Applicant

Date

RECOMMENDATION OF ADMISSIONS COUNSELOR
I have discussed with the applicant the reasons why he (she) left Job Corps and now wants to return. I have explained to the applicant
the eligibility requirements for readmission outlined in Chapter 1, Job Corps Policy and Requirements Handbook. I am satisfied that the
youth is sincere in his (her) desire to return to Job Corps and complete the training. I recommend that the youth be readmitted.
Signature of A.C.

OMB Expiration Date 02/28/07

Date
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ETA 652 (REV 5/98)