ETA-655 Statement from Court

Date: 11/21/2006

Statement from Court

Student ID:

Applicant Information:

SSN:

Name:

Page 1 of 1

Birth Date:

Sex:

Address:
Counselor Office Information:
Name:
Address:
Court Information:
Institution Name:
Address:

Phone:

Contact Name:

Title:

The following information is to be completed by the Court, Supervising Agency, or Authorized Person:
Date applicant first entered the jurisdiction:

Date applicant was/will be released from jurisdiction:

List all the complaints which were sustained:

Describe applicant's adjustment while under supervision of the court or other agency:

Describe any aspects of the applicant's background, personality, or behavior which the Job Corps should know about:

Describe any difficulties the applicant might have in adjusting to the Job Corps:

Can the applicant be expected to:
Live and work well with others?

Respond to discipline?

Behave properly in the community?
Be free of all court-imposed obligations?

Benefit from Job Corps?

Not prevent others from benefiting from the program?
Be released/suspended from all financial oblications until Job Corps Termination?

Is a Court appearance pending?
If applicant is currently under agency jurisdiction or supervision, will agency:
Release applicant upon departure for Job Corps?

Authorize Job Corps to send applicant to another state upon completion?

Agree not to excersise personal or face to face supervision during enrollment?

Permit applicant to leave the state while enrolled?

Does Agency wish a report from Job Corps if arrested during enrollment:
Prior to court disposition?

Signature of Point of Contact

OMB Expiration Date 02/28/07

Subsequent to court disposition?

Date

ETA 655 (REV 10/01)