DOL Intake Form

Department of Labor Building Pathways

DOL Building Pathways to Infrastructure Jobs Grant Program

Please note, this is an enrollment agreement form. Confirmation of acceptance and enrollment and potential grant funding will be communicated in a follow up email. Make sure to check your SPAM email for updates.

* Please complete all required fields

Student Information

First Name

Last Name

Birthdate

Nation of citizenship

Social Security Number (SSN)

*This grant requires we request your social security number.

Contact Information

Personal Email Address

Work Email Address

Personal Phone Number

Opt-in to Receive Text (SMS) Messages

Yes

No

Address

Mailing Address

Country

Street

City

Region

Postal Code

Have you ever served in the U.S. Armed Forces?

Yes

No

Prefer not to answer

Active Duty (current status)

Please note if you have any "disability”, as defined in Section 3(2)(a) of the Americans with Disabilities Act of 1990 (42 U.S.C. 12102)

Yes

No

Prefer not to answer

Supporting Documentation

Please upload a copy of your valid, government issued ID as proof of residency.*

Education

Highest Academic Level Completed*

Major/program of study (or) degree awarded *

Please note the highest grade completed if HS/GED has not been completed.

FGCU Affiliation*

Current FGCU student

FGCU alumni

FGCU faculty/staff

No FGCU affiliation

Proof of US citizenship or green card or work visa is required for grant funding consideration. Paid participants do not need to be US citizen.*

I am a US citizen and if selected can provide necessary documentation.

I am not a US citizen, but I have a work visa (Green card and can provide documentation. 1-B or Optional Practical Training OPT) and can provide documentation.

I am not a US citizen.

Other

If Other, please specify:

Supporting Documentation (Please upload your VISA working papers, documentation, etc.)*

Please select which program you are applying for: *

Supply Chain Management Skills Training Course

Analytics Skills Training Program

Demographic Information

Florida Gulf Coast University must collect data from recipients of a tuition and fee award for submission the Department of Labor. Thank you for sharing your information so that we can provide you and others with support and demonstrate the effectiveness of these programs. If you have any questions regarding the data collection and how your information will be shared, please email the contact below and reference the Department of Labor (DOL) and your program for additional information.

Contact us at continuinged@fgcu.edu for assistance.

All participants must eligibility requirements as outlined by the Department of Labor

Please select one of the following:*

𝐔𝐧𝐞𝐦𝐩𝐥𝐨𝐲𝐞𝐝 𝐖𝐨𝐫𝐤𝐞𝐫: An unemployed worker is an individual who is without a job and is available to work. Examples: full-time students who are not currently working, retired individuals seeking to return to work, or recent high school graduates without a job.

𝐔𝐧𝐝𝐞𝐫𝐞𝐦𝐩𝐥𝐨𝐲𝐞𝐝 𝐖𝐨𝐫𝐤𝐞𝐫: An individual who is not currently connected to a full-time job commensurate with the individual’s level of education, skills, or wage and/or salary earned previously, or who has obtained only episodic, short-term, or part-time employment. Example: individuals in any occupation who are not working at a skill and/or pay level commensurate with their level of education, skill, or previous payamily

𝐈𝐧𝐜𝐮𝐦𝐛𝐞𝐧𝐭 𝐖𝐨𝐫𝐤𝐞𝐫: An individual already employed, either with an employer partner or another employer, at program enrollment, but who needs training to upgrade their skills to secure full-time employment, advance in their career, or retain their current position in an H-1B occupation and industry. The training provided to incumbent workers is either 1) developed in collaboration with an employer partner with which the individual is employed, or 2) for individuals who are employed at the time of enrollment by a non-partner employer, but who need additional skill training to improve their opportunities for middle- and high-skilled jobs in the target H-1B industries or occupations. Examples: currently employed individuals who want to advance to a higher position or currently employed individuals who want to transition to a new field.ort our family

𝐎𝐭𝐡𝐞𝐫: (Please note that the examples provided above are not exhaustive categorizations of all employment situations (you may be contacted for further information))

Gender

Male

Female

Prefer Not to Answer

Ex-offender status at the time of program entry*

Yes

No

Do not wish to answer

The number of individuals living in my household below the age of 18*

Professional or Other Work Experience

Please list your current employment information in the fields below.

Current or Last Employer Name*

Position Held*

Dates of Employment*

Start

End

Excel Skills*

Writing Skills*

Agreement Certification Statement and Participation Consent

Participant Consent Form *

I consent- I agree to take part in this study.

Refusal of consent- I do not agree to take part in this study.

Your personal information will only be shared for research purposes.

I understand that applying for the Department of Labor (DOL) Tuition assistance program does not guarantee acceptance into the program. Also, if I am admitted,* (check all to qualify)

I will need to stay on track with my weekly Modules

Submit my on-the-job training plan after Module 2 has been completed

Complete a project with the current employer (4 weeks after completing this course) or pursue an on-the-job training through a paid internship at a company

I understand my certificate of completion will not be given unless my on-the-job component has been completed which is required by the DOL grant.

I certify that I understand the above statement, by signing.

Yes

No

Enrollment & Participation Requirement:

IMPORTANT: APPLICANT MUST READ THE FOLLOWING STATEMENT AND PROVIDE A SIGNATURE

Students must complete introductory assignments or acknowledge enrollment within the first week of the course start date.

Students should not fall behind for more than 3 weeks on coursework. Failure to stay current will result in being dropped from the course and may require repayment of the DOL grant. Once dropped, students lose access to course materials and cannot earn any credentials related to the course.

I certify that I understand the above statement, by signing.

Click to Sign...