Form VA Form 22-10282 VA Form 22-10282 IBM SKILLSBUILD TRAINING PROGRAM INTAKE APPLICATION

IBM SKILLSBUILD TRAINING PROGRAM INTAKE APPLICATION
WHAT IS THE IBM SKILLSBUILD PILOT TRAINING PROGRAM?
The IBM SkillsBuild Program is an IBM-sponsored training program administered by VA to provide free virtual Information
Technology (IT) training. SkillsBuild is a free online learning platform that provides adult learners with the opportunity to gain or
improve IT skills that meet the needs of employers in the High-Technology industry. VA will provide the opportunity for Veterans,
Service members, and their families to access free, self-paced, virtual training and credentials in Cybersecurity and Data
Analytics. This virtual training in the field of Cybersecurity and Data Analytics is an enhanced resource for Veterans and
transitioning Service members who are seeking job training and credentials to pursue a career in Technology.

HOW DO I QUALIFY TO MEET THE CRITERIA TO PARTICIPATE?

APPLICANT INTERESTED IN PARTICIPATING IN THE SKILLSBUILD TRAINING PROGRAM MUST
MEET THE FOLLOWING INTAKE AND REGISTRATION REQUIREMENTS/CRITERIA:
Intake Eligibility Criteria:
· Applicant must be a Veteran, Service member, or dependent who has previous or current entitlement under the GI Bill
program.
Intake Registration Requirement:
· Registration is on a first-come, first-served basis.

WHERE DO I SEND IN MY COMPLETED APPLICATION? When completed, this application can be submitted
electronically via E-mail.
o Submit electronically via E-mail to: [email protected].

PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the
Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., VA sends educational forms or letters with a veteran's identifying
information to the veteran's school or training establishment to (1) assist the veteran in the completion of claims forms or (2) VA obtains further information as
may be necessary from the school for VA to properly process the veteran's education claim or to monitor his or her progress during training) as identified in the
VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your obligation to respond is required to obtain or retain benefits under this cost-free IBM Skillsbuild Cybersecurity Training Program. While you do
not have to respond, VA cannot consider you approved to participate until we receive this information per (38 U.S.C. 3452(b) and 3501(a)). Your responses are
confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine your eligibility to receive VA approval to participate in the cost-free VA IBM Sponsored
Skillsbuild Cybersecurity Training Program. We cannot provide you any education benefits available under this program until we receive this information (38
U.S.C. 5101). We estimate that you will need an average of 10 minutes to review the instructions, find the information, and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if
this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at http://www.reginfo.gov/public/do/PRAMain. If
desired, you can call 1-888-GI-BILL-1 (1-800-442-4551) to get information on where to send comments or suggestions about this form. If you are hearing
impaired, call 1-888-829-4833.
VA FORM
XXXX

22-10282

Page 1

OMB Approved Number 2900-NEW
Respondent Burden: 10 Minutes
Expiration Date: XXXXXXXXX

IBM SKILLSBUILD TRAINING PROGRAM INTAKE APPLICATION
IMPORTANT: Complete this application to apply for VA Approval to participate in the IBM SkillsBuild Training Program. (This form must be completed in its entirety.)

PART I - APPLICANT INFORMATION
1. NAME (First-Middle-Last)

2. SEX OF APPLICANT (How would you describe your gender?)
MALE

FEMALE

TRANSGENDER MAN

TRANSGENDER WOMAN

NON-BINARY/THIRD GENDER

PREFER NOT TO SAY

OTHER:
4. E-MAIL ADDRESS (Required)

3. SOCIAL SECURITY NUMBER OF APPLICANT

5. MOBILE NUMBER (Include Area Code)

6. HOME NUMBER (Include Area Code)

7. TRAINING COHORT DATE
8. RACE/ETHNICITY (Please select all that apply for how you describe your race.)
WHITE

BLACK OR AFRICAN AMERICAN

ASIAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

HISPANIC OR LATINO

AMERICAN INDIAN OR ALASKA NATIVE

MIDDLE EASTERN OR NORTH AFRICAN

OTHER:

PART II - MILITARY AFFILIATION
9. SELECT MILITARY AFFILIATION
SPOUSE

VETERAN

CHILD

ACTIVE DUTY

NATIONAL GUARD

INDIVIDUAL READY RESERVE

RESERVIST

10. ARE YOU CURRENTLY USING OR PREVIOUSLY USED ANY VA EDUCATION BENEFITS?
YES

NO

PART III - SKILLSBUILD PROGRAM CHOSEN
11. WHAT SKILLS/TRAINING PROGRAM WOULD YOU LIKE TO ATTEND? (Please check only one)
CYBERSECURITY - BASIC

CYBERSECURITY - ADVANCED

DATA ANALYTICS - BASICS

DATA ANALYTICS - ADVANCED

OTHER (If "other," please describe)
12. IF APPLYING FOR AN ADVANCED COURSE, PLEASE DESCRIBE YOUR PREVIOUS TRAINING OR EXPERIENCE IN THE SUBJECT AREA AND CHECK ONE OF THE
BOXES BELOW: (Comment)

BEGINNER

INTERMEDIATE

13A. ARE YOU CURRENTLY EMPLOYED?
YES

EXPERT
13B. ARE YOU CURRENTLY WORKING IN THE HIGH TECHNOLOGY INDUSTRY?

NO (If "No," skip to Question 13D.)

COMPUTER
PROGRAMMING

DATA
PROCESSING

$20,001-$35,000

$35,001-$50,000

INFORMATION
SCIENCES

MEDIA
APPLICATION

13D. WHAT IS YOUR HIGHEST LEVEL OF EDUCATION?

13C. WHAT IS YOUR CURRENT SALARY RANGE?
<$20,000

COMPUTER
SOFTWARE

(High School, Bachelors, etc.)

$50,001-$75,000

>$75,000

PART IV - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief, and I hereby authorize the release of my answers to the
above questions to the Department of Veterans Affairs (VA) as required to determine my acceptance to participate in the Skillsbuild program.
PENALTY: Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of these or other benefits and
criminal penalties.
14. SIGNATURE OF APPLICANT (DO NOT PRINT)

VA FORM
XXXX

22-10282

15. DATE SIGNED

Page 2