BIA 8205 Application for Job Placement and Training Services

Form BIA 8205 U. S. DEPARTMENT OF THE INTERIOR OMB No. 1076-0135

Rev 01/2004 BUREAU OF INDIAN AFFAIRS Exp. Date XX/XX/XX

APPLICATION FOR JOB PLACEMENT AND/OR TRAINING ASSISTANCE

INFORMATION RECORD Social Security No. - -

Name ( Last, First, Middle Initial )			Mailing Address:			Date of Birth: Telephone No. ( )
Veteran Yes No	Marital Status Widowed Married Single Separated Divorced			___Others in Household, non-dependent Explain:		Number of Dependents Dependents Children in School
Services Applying for: ____Job Placement (JP) ____Job Training (JT) ____Other		Request (Circle) Initial JP Repeat 1 2 3 JT Repeat 1 2			In Case of Emergency Name: Address: Telephone No.
Education: Highest Grade Completed: Schools attended and Date(s):
Type of Training or kind of Job you are interested in: Do You have any physical limitations that would interfere with your training or employment? Yes No If yes, please explain Training or Job Location Desired: For Training: Course No. And Title: School and Address: Do you have income from any source? Yes No If yes, please explain
EMPLOYMENT RECORD: (List your three most important periods of employment, starting with the most recent.) From: To: Employer Name and Address: Job Title: Description of Duties: Reason for Leaving:
From: To: Employer Name and Address: Job Title: Description of Duties: Reason for Leaving:
From: To: Employer Name and Address: Job Title: Description of Duties: Reason for Leaving:

Form BIA 8205 U. S. DEPARTMENT OF THE INTERIOR OMB No. 1076-0135

Rev. 01/2004 BUREAU OF INDIAN AFFAIRS Exp. Date XX/XX/XX

Page 2

TO BE INITIALED BY APPLICANT FOR TRAINING ONLY:

I hereby apply to attend the school indicated on this application and agree to follow all rules, regulations and attendance requirements of the school and to the best of my ability will satisfactorily complete the course, which I have selected. I further agree that the funds issued me for training purposes by the Bureau of Indian Affairs will be so used or repayment will be made to the U. S. Government. I understand that if I am eligible for other training funds, such as PELL Grant, etc., this will be included when computing my financial aid package and I agree to use those funds for the purpose intended. I authorize the school to release grade, attendance, and income information to the Bureau of Indian Affairs’ personnel. (Initial)

PAPERWORK REDUCTION ACT AND PRIVACY ACT STATEMENT:

This information is being collected to determine the eligibility for Job Placement & Training services. Response to this request is required to obtain financial assistance. It is estimated that responding to the request will take an average of 30 minutes to complete. This includes the amount of time it takes to review instructions, gather and maintain the data needed, and complete the form. In compliance with the Paperwork Reduction Act of 1995, as amended, this collection has been reviewed by the Office of Management and Budget and assigned a number and expiration date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to: Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, N.W., Mail Stop 3071, Washington, D.C. 20240. Please note: comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state that prominently at the beginning of your comment. We will honor your request to the extent allowable by law.

1. The authority for solicitation of the information on this form is 25 U.S.C. 13 (42 Stat. 208) and P.L. 84-959 (70 Stat. 986) as amended by P.L. 88-230 (77 Stat. 471, 25 U.S.C. 309)

2. Disclosure of the requested information by the applicant is voluntary, but required to obtain a benefit.

3. The purpose of this information collection is to determine your eligibility for services.

4. The routine use of this information by the BIA and school counselors is to evaluate your request and to assist you before and during your Job Placement & Training activities. After completion of Training, or a Job Placement, parts or all of the information in your application will be provided to employers who are considering you for employment. The application will be used in a routine manner by counselors working with you who need background information, and by those persons involved in financial control who need budgeting information contained in the application.

5. Failure to provide requested information may result in a delay (or denial) in receiving the training or job placement assistance you are seeking.

I have read the above statement. I hereby provide the required information and authorize the use of such information to the extent of the uses specified in the statement.

______________________________________________

(Applicant’s Signature) (Date) (Interviewer’s Signature) (Date)

FOR AGENCY USE

I certify that Is Degree of Indian blood, and a member of the ________________________________Tribe and is/is not eligible for training or job placement services. Individual is serviced by ( Agency) of ( Region).

Recommended by: Approved:___________ _________________________ Title________ (Agency Superintendent)

If required, Regional Action taken: Approved Disapproved Date:_________________

(Regional Director)__________________________________

DISPOSITION OF THIS CASE: Training completed on (date )

Trainee is currently a permanent employee and has remained employed for at least 90 days YES/NO.

Earnings: $_____________PRE-Job Placement & Training Service $_____________POST-Job Placement &Training Service

Upon training completion, Trainee received; ___Certificate, ___Degree (2yr)

__Trainee dropped out (reason):

Case worker’s Signature and Date