Form ETA 6-61 ETA 6-61 CIS Notice of Separation

Center Information System
ABC Job Corps Center
JOB CORPS NOTICE OF SEPARATION
NAME OF STUDENT(LAST, FIRST, MI)

STUDENT ID

STUDENT'S HOME ADDRESS, TELEPHONE NUMBER

GENDER

Enrollment Age:
Separation Age:

DATE OF ENROLLMENT

ENROLLMENT TYPE

DATE OF SEPARATION

PAID DAYS

SEPARATION TYPE

SEPARATION REASON

TENURE DAYS

READMISSION STATUS:
A. RECOMMEND STUDENT FOR READMISSION
AT A LATER DATE?

B. IF READMITTED, RECOMMEND
REASSIGNMENT TO THIS CENTER?

WAS STUDENT ELIGIBLE FOR CAREER
DEVELOPMENT SERVICE

WAS STUDENT A
GRADUATE?

GED STATUS

IF NO, REASON:
ADMISSION COUNSELOR:

CAREER DEVELOPMENT SERVICES PROVIDER:

CODE

CODE

NAME

NAME

ADDRESS

ADDRESS

CENTER:
CODE
NAME

ABC Job Corps Center

ADDRESS

NAME AND SIGNATURE OF AUTHORIZED OFFICIAL

FOR OFFICIAL USE ONLY

DATE: