ETA 640 Student Profile

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

ETA FORM 640 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Student Profile

		Center Name:
		Center Address:
		Center Telephone:
		Center Fax:

Personal Information
Legal Name		Student ID
Date of Birth		Legal Resident Status
Place of Birth
Sex	☐ Male ☐ Female	Race
Address		Phone Number
Marital Status		Dependents
Family Status		Number in Family
Family Income
License Number		License Status
Parental Consent		Pass Consent
Initial HSD/HSE Status		Number of Months Out of School
Highest Grade Completed		Number of Weeks Unemployed
Hourly Wage of Previous Job
Exam Date		Height	Weight
Screener
Admissions Representative		OA Manager

Enrollment Information
Current Enrollment
Enrolled		Arrival
Enrollment Age		Type of Enrollment
Residential Status		Dorm/Room/Bed
Admissions Representative
Job Corps Daycare		Allotment
Tenure Days		Paid Days

Primary Contact Information
Name		Relationship
Address		Guardian
Home Phone		Work Phone Ext
Residential Status		Dorm/Room/Bed

Alternative Contact Information
Name		Relationship
Address		Guardian
Home Phone		Work Phone Ext
Residential Status		Dorm/Room/Bed

Evaluation Information
Finalized Date	Evaluation Type	Average Score	Comments

Duty Status	Start Date	End Date	Total Days	Training Days

TABE Data

TABE 11/12
Test Type	Test Form	Test Level	Valid Test	Test Date	Scale Score	Lexile/ Quantile	EFL	Educational Functioning Level

HSD/HSE Data
Status	Date	State	Test Type	Literature	Math	Science	Social Studies	Writing	Essay

CTT/Vocation Data
Type	ONET Code	Title	NTC	Start	Complete	Level

Course History
Course	Start Date	End Date	Status

Water Safety
	Status	Added By	Added Date	Modified By	Modified Date
Water Safety Status
Swimming Proficiency

Student: I the undersigned, certify that all information on this form is accurate.
Legal Name
SIGNATURE:		DATE: