ETA 652 Job Corps Applicant Data Sheet

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Applicant Data Collection Form

Purpose of this form: The purpose of this form is to collect data from individuals applying to Job Corps for the purpose of determining eligibility to the program and gathering information pursuant to the Workforce Innovation & Opportunity Act (WIOA) Participant Individual Record Layout (PIRL) requirements. Applicants with a disability are reminded that they have the right to request a reasonable accommodation at any time during to complete and review this form.

Section A: Job Corps Applicant Information

Personal Information			Income Eligibility
Legal Name	Smith, Johnathan		Family/Household Status	Family Member
Preferred Name	John		Estimated Annual Income	$0.00
Date of Birth	7/6/2000		Receiving Public Assistance	Yes
Birth Country	United States of America		Houselessness/Homelessness	No
Race	Black or African American		Receiving Free or Reduced School Lunch	No
Ethnicity	Not Hispanic or Latino		Victim of Human Trafficking	No
Preferred Language	French		Left Home as a Runaway	No
Gender Identity	Male		Experience in Foster Care System	No
Sex	Male
Pronouns	He/him/his		Legal Residency Type
Social Security Number	XXX-XX-XXXX		U.S. Citizen
Address	1 N St, Washington, DC 12345
Email Address	[email protected]
Phone Number	(111) 111-1111		Military Experience
			Prior Military	No
Additional Contacts			Eligible Veteran Status	N/A
Primary Contact	Smith, Jane		Campaign Veteran	N/A
Email Address	[email protected]		Disabled Veteran	N/A
Phone Number	(222) 222-2222		Homeless Veteran	N/A
Alternate Contact	Smith, Jim		Date Of Military Separation	N/A
Email Address	[email protected]		Transitioning Service Member	N/A
Phone Number	(333) 333-3333
			Supplemental Assistance
Employment History			Temporary Assistance for Needy Families	No
Employment Status	Currently Employed		Supplemental Security Income/Social Security Disability Insurance	No
Number Of Weeks Unemployed	N/A		General Assistance/Refugee Cash Assistance	No
Unemployment Compensation Eligible Status	N/A
Current Employer	ABC, Inc.		Family Care
Industry	Manufacturing		Marital Status	Single
Job Title	Assembler		Allotment Eligibility	No
Number Of Months Employed	8 months		Dependent Children	No
Hourly Wage	$15.00		Child Care Arranged	N/A
Estimated Hours Per Week	40
Previous Employer	N/A		Criminal History Review
Industry	N/A		Criminal history background check is complete.
Job Title	N/A
Number Of Months Employed	N/A
Hourly Wage	N/A
Estimated Hours Per Week	N/A

Education
High School Diploma/High School Equivalency	Yes
Diploma Type	Standard Diploma
Completed High School	No
Highest Grade Completed	11
Time Out of School	24 mos.
Limited English Proficiency	No
Name of Last High School Attended	North High School
City	Washington
State	DC

I the undersigned, certify that all information on the application form is accurate. APPLICANT SIGNATURE:

DATE:

U.S. Department of Labor Employment and Training Administration Job Corps Application

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Section B: Applicant Commitment Statement

I understand that enrolling into the Job Corps program is a choice, and that only qualified and committed individuals will be accepted. The Job Corps program is an education and training program that helps young adults develop or enhance the skills that they need to secure an in-demand, higher-wage, and/or critically-needed job and a career path that provides self-sustaining income and opportunities for career growth. ACKNOWLEDGEMENT OF BENEFITS: Job Corps provides a safe, drug-free living environment where I can attain:
Academic Education:	Academic skills that I need to succeed in the workplace (High School Diploma, High School Equivalency, and post-secondary preparation).
Career Training:	Occupational skills that I need to succeed in today’s competitive job market.
Employability Skills:	Workforce preparation skills that I need to be successful in a job and in everyday life.
Placement:	Job search skills and assistance in finding a job when I complete my training.
APPLICANT SIGNATURE:			DATE:

U.S. Department of Labor Employment and Training Administration Job Corps Application

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Section C: Acknowledgement of Expectations

I understand that violence, drug or alcohol use and harassment, including sexual harassment are not tolerated at Job Corps. 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 the center. I understand that I will be living in a diverse and inclusive environment and sharing a dormitory with other students. I understand that I will be responsible for cleaning my living area and sharing responsibility with other students to maintain a safe environment. I understand that if I have problems while in the Job Corps program or on the Job Corps campus, I will contact my Center Counselor to work out the problems. I understand that I will be given an orientation to the Job Corps’ rules and regulations and that I must abide by these policies to remain in the program. I understand that in order to obtain the benefits Job Corps has to offer, I must attend classes and complete the program. I certify that I understand the expectations of the Job Corps program. If I am accepted to Job Corps, I agree that I will accept these conditions and commit to fully participate in the program.
APPLICANT SIGNATURE:		DATE: 7/6/2022

U.S. Department of Labor Employment and Training Administration Job Corps Application

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Section D: Job Corps Applicant and Parent / Guardian Consent Record

The admissions representative must read each item on this consent form to the applicant, and to the parent/guardian of the applicant if under the age of 18 (unless legally emancipated), confirm that they understand it, and have the applicant (and parent/legal guardian, if applicable) sign the form. I (we), the undersigned, certify that all information on the application form is accurate. I (we) consent to the enrollment of the above-named individual into the 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 punished by law. I (we) understand that, if applicant is required to be registered with the Selective Services System, I (we) authorize Selective Services to register applicant/student at the age of 18. I (we) further understand that if the applicant/student is already registered, the automatic registration process will not register the applicant/student 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/or state health department when required by law. I (we) have been provided with a personal copy of Job Corps’ Privacy Act statement. I (we) have read the statement and understand the contents. I (we) have been provided information about Job Corps, life on a Job Corps center, career training offerings, and job outlook information. I (we) have been told what Job Corps expects of me (my child/ward) as a student. All of my (our) questions have been answered. I (we) understand my (our) responsibility to keep Job Corps leaders informed of any address changes. I (we) authorize Job Corps to gather information about my employment after participating in Job Corps training. I (we) authorize Job Corps to contact me (us) via phone calls, emails and/ or text messages to gather information about my Job Corps application, my program participation, and my post-enrollment experiences.
APPLICANT SIGNATURE:		DATE:
PARENT OR LEGAL GUARDIAN SIGNATURE:		DATE:

U.S. Department of Labor Employment and Training Administration Job Corps Application

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Section E: Job Corps Zero Tolerance Student Conduct System

Every student has the right to participate in the Job Corps program without being subjected to violence or drug abuse. I have been informed about Job Corps’ Zero Tolerance for violence policy and agree that while I am enrolled in the Job Corps program, I will abide by it. I understand that if I commit any of the offenses listed below, I will be immediately removed from the program, and will lose the chance to be present for a Campus Review Board. However, I will be able to make a written statement on my behalf and will be allowed to appeal the decision of the board. The offenses that require automatic removal from the program are: Possession of a weapon on campus or while under campus supervision, including but not limited to guns or ammunition, knives of any size, explosives, or homemade weapons. Assault with the intent to do bodily harm, with or without the use of a weapon; the threat of assault; or a threat to safety, including threats expressed verbally, via text, email, blog, or social media. Sexual assault, with or without bodily harm. Possession or distribution of drugs on campus or under campus supervision. Use of drugs as evidenced by a positive drug test. Possession, consumption, or distribution of alcohol while on campus or under campus distribution, or abuse of alcohol. Arrest for a felony or violent misdemeanor on or off campus, or conviction of a felony or misdemeanor that occurred while enrolled. Robbery or extortion. Arson. Cruelty to animals. Inciting a disturbance or creating disorder. I understand that other offenses may result in disciplinary action, which may include separation from the program. I understand that my refusal to sign this Zero Tolerance certificate will prevent my enrollment in Job Corps.
NAME:		APPLICANT/STUDENT ID:
APPLICANT SIGNATURE:		DATE:

U.S. Department of Labor Employment and Training Administration Job Corps Application

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Section F: Authorization for Release of Criminal History Record Information

I _______________________________________________ authorize the Department of Labor (DOL), through its background investigation services provider, to conduct a criminal history record information (CHRI), known herein as “background check”, for purposes of determining my eligibility for the Job Corps program under the Workforce Innovation and Opportunity Act, 29 U.S.C. 3191 et seq. The Defense Counterintelligence Security Agency (DCSA) performs background checks and other investigative services for Federal agencies, including DOL.

I further authorize any investigator, special agent, or other duly accredited representative of DOL and/or DCSA to request and receive CHRI about me from criminal justice agencies, or other appropriate record custodians, for the purpose of determining my eligibility for Job Corps, in accordance with 29 U.S.C. 3195 and Executive Order 13869, Sec. 2(c)(v).

The collection, maintenance and disclosure of background check information is governed by the Privacy Act. I understand that the background check information received will be maintained, by both DOL and DCSA, in accordance with the Privacy Act, in their respective records system.

I acknowledge that I received the Job Corps Privacy Act Statement, which explains how background check information will be maintained and used by DOL.

Within DCSA, the background check will be maintained in the Department of Defense Personnel Vetting Records System, “DUSDI 02-DoD”. I understand that I may request a copy of the DCSA background check records as may be available to me under the law. I also understand the background check records maintained by DCSA may be disclosed without further consent to DCSA personnel and shared with other authorized recipients for routine uses, and, for other purposes permitted under subsection (b) of the Privacy Act of 1974, as amended (5 USC §552a). The most common routine use pertains to personnel vetting investigations, determinations, and adjudications. A complete list of the routine uses can be found in the “DUSDI 02-DoD” system of records notice at: https://www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records. Any information gathered pursuant to this background check may be disclosed by the Government only as authorized by law.

INFORMATION RELEASE AUTHORIZATION:

I understand that disclosure of the personal information below is voluntary; and that failure to provide the required information may result in DOL and DCSA’s inability to complete a background check and may prevent DOL from making a determination regarding my eligibility for Job Corps.

My signature below authorizes the release of the requested background check information. This authorization remains in effect for a period of 1 year from the date signed. A copy of this authorization shall have the same force and effect as the signed original.

FULL LEGAL NAME OF APPLICANT (PRINT)

LAST NAME:	FIRST NAME:		MIDDLE NAME:
OTHER NAMES USED:
APPLICANT SOCIAL SECURITY NUMBER:
APPLICANT DATE OF BIRTH:
APPLICANT SIGNATURE:			DATE:
PARENT OR LEGAL GUARDIAN SIGNATURE: (IF APPLICANT IS UNDER 18 YEARS OF AGE)			DATE:

U.S. Department of Labor Employment and Training Administration Job Corps Application

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Section G: For Job Corps Use Only - Recommendation of Readmission

Leave blank if applicant is not a readmit.

I ______ ________, Job Corps Admissions Representative, have discussed with the applicant the reasons why the individual left Job Corps and now wants to return. I have reviewed with the applicant the requirements for readmission as outlined in Job Corps policy. I am satisfied that the applicant is sincere in the desire to return to Job Corps and complete the training. The applicant states they have never been readmitted to Job Corps, and that if new information shows that the applicant has previously been readmitted they will not be eligible for enrollment. I recommend that the applicant be readmitted.
ADMISSIONS REPRESENTATIVE SIGNATURE:		DATE:
Privacy Act Notice: All request for personal information about students must be treated as requests under the Freedom of Information Act and the Privacy Act of 1974, and handled pursuant 29 CFR Parts 70 and 70a and 45 CFR Parts 160 and 164. Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0025). Please do not submit completed forms to this address.

U.S. Department of Labor Employment and Training Administration Job Corps Application

ETA FORM 652 OMB Control No. 1205-0025 Expiration Date: 4/30/2023

Section H: For Job Corps Use Only – Admissions Information

Admissions Office Information
Screener Code	AAAAAA
Date Application Opened	6/1/2022
Date Application Completed	7/1/2022
Admissions Representative	Jane Doe
Application Type	New
Admissions Office Address	456 South St, Washington, DC 12345
Admissions Office Phone Number	(444) 444-4444
Student ID	123456
Campus ID	12345

Internal Review
Review	Complete
Approved	Yes
Remarks	No
Previous Enrollment Date	N/A
Separation Date	N/A
Campus Where Separated	N/A
Destination of Applicant After Separation	N/A
Reason(s) For Separation	N/A
Reason(s) For Reapplying	N/A
Military Covered Person Entry Date	N/A
Criminal Conviction	No
Disqualifying Conviction	No
Basic Skills Deficient	No
Requires Additional Education, Career Training, or Workforce Preparation Skills	Yes
Cultural Barriers	No

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