Diesel Technology. Veteran Training Program TRAIN FOR A NEW CAREER IN DIESEL TECHNOLOGY IN JUST 14 WEEKS AT NO COST TO VETERANS!

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1 Diesel Technology Veteran Training Program TRAIN FOR A NEW CAREER IN DIESEL TECHNOLOGY IN JUST 14 WEEKS AT NO COST TO VETERANS! Discover Goodwill honors your commitment to our country and is excited to roll out our Diesel Technology Training program to veterans in the summer of 2016 (May 23 - August 31). Registration, DOT physical (Goodwill-paid), drug test and background check are required. In partnership with Pikes Peak Community College, we are offering: 14-week academic instruction and job-related training on Discover Goodwill s fleet vehicles Two certificates earned upon completion, including Diesel Lube Technician and Diesel Fleet Maintenance Technician with 609 Refrigeration Certification CDL training Job placement with employers ready to hire! For more information, please contact Miriam Yost at

2 Diesel Technology Certificate Program Application Packet Discover Goodwill honors your commitment to our country and is excited to roll out a Diesel Technology Training program to Veterans summer of 2016 (May 23rd-August 31 st ). In partnership with Pikes Peak Community College and U.S. Truck Driving School, we will offer two diesel mechanic certifications and a CDL training program. Registration, DOT physical (Goodwill paid), drug test and background check is required. In order to find the most suitable candidates for this program that are eligible for the funding opportunities from our partners, the enclosed application packet consists of the following required materials: Diesel Certificate Program Application ReHire Colorado paperwork Pikes Peak Workforce Center Checklist (Items to be collected during interview process) Please or mail your completed application by May 2, 2016 to: Discover Goodwill Attn: Miriam Yost 1460 Garden of the Gods Road Colorado Springs, CO MYost@DiscoverMyGoodwill.org Phone:

3 Diesel Technology Certificate Program Application PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE Today s Date: Date of Birth: Name: Last First Middle Maiden Present address: Number Street City State Zip How long at address above? Telephone: ( ) address: MILITARY Have you ever been in the armed forces? YES NO Are you now a member of the National Guard? YES NO Specialty (MOS, AFSC, or applicable additional duties) Date Entered: Discharge Date: Type of discharge: Form DD 214 available? YES NO Are you currently receiving a VA pension/disability? YES NO If yes, at what percentage? YES NO Are you retired from the military? YES NO If yes, what was your highest rank? Criteria 1 ELIGIBILITY This Diesel Certificate program takes place May 23rd through August 31 st, The program consists of two classes: Diesel Lube Technician and Diesel Fleet Maintenance Technician. The schedule will be 10 weeks for classroom time and 4 weeks for a hands-on internship and CDL training. The hours are Monday through Friday 8:00 a.m.to 5:00 p.m. Are you able to commit to the full Diesel Certificate Program? YES NO Initial Here Our Business is Changing Lives Page 1 5

4 Criteria 2 There will be preference given to applicants that have a family income below 150% of the federal poverty level, adjusted for family size (VA compensation and benefits are not counted in this income). Do you meet this criteria? YES NO Criteria 3 Signature This certification program has a Commercial Driver s License (CDL) training component, requiring that you pass a DOT physical examination prior to employment. Some of the key health risks that physicians screen for or want to see further documentation on health history are: Illness or injury within the last 5 years High blood pressure Head/Brain injuries, disorders or illnesses Muscular disease Seizures, epilepsy Shortness of breath Eye disorders or impaired vision (except corrective lenses) Liver disease Ear disorders, loss of hearing or balance Digestive problems Heart disease or heart attack; other cardiovascular condition Fainting, dizziness Heart surgery (valve replacement/bypass, angioplasty, pacemaker Stroke or paralysis Lung disease, emphysema, asthma, chronic bronchitis Kidney disease, dialysis Diabetes or elevated blood sugar controlled by diet or pills or insulin Spinal injury or disease Nervous or psychiatric disorders e.g. severe depression Chronic low back pain Sleep disorders, pauses in breathing while asleep, daytime sleepiness, Regular, frequent alcohol use loud snoring Loss of, or altered consciousness Missing or impaired hand, arm, foot, leg, finger, toe Narcotic or habit forming drug use (note there is a SPE certification program that allows persons with the loss of a foot or limb or with functional impairment to qualify under the Federal Motor Carrier Safety Regulations by use of prosthetic devices or equipment modifications, which enable them to safely operate a commercial motor vehicle). Do you have any concerns in meeting this criteria or providing documentation to the administering physician if you answered yes to any of these conditions? YES NO Initial Here This program includes frequent bending and routinely lifting up to 45 lbs. Are you able to meet this criteria? YES NO Initial Here Additional comments on eligibility section: Our Business is Changing Lives Page 2 5

5 EDUCATION TYPE OF SCHOOL NAME OF SCHOOL LOCATION NUMBER OF YEARS COMPLETED High School MAJOR & DEGREE College Vocational or Trade School Have you ever been convicted of a crime? YES NO If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation Do you have a driver s license? YES NO What is your means of transportation? Driver s License Number: State of issue: Operator Commercial (CDL) Expiration Date: Please list your work experience, including any volunteer work for the past five years beginning with the most recent position held. Name of Employer: Address: City, State: Phone number: WORK EXPERIENCE Name of last supervisor: Employment date from: to : Reason for leaving: Our Business is Changing Lives Page 3 5

6 List the job tasks and duties, skills used or learned, advancements or promotions: Name of Employer: Address: City, State: Phone number: Name of last supervisor: Employment date from: to: Reason for leaving: List the job tasks and duties, skills used or learned, advancements or promotions: Name of Employer: Address: City, State: Phone number: Name of last supervisor: Employment date from: to: Reason for leaving: List the job tasks and duties, skills used or learned, advancements or promotions: Name of Employer: Address: City, State: Phone number: Name of last supervisor: Employment date from: to: Reason for leaving: Our Business is Changing Lives Page 4 5

7 List the job tasks and duties, skills used or learned, advancements or promotions An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information to describe your interest in the field of diesel mechanics and what you hope to gain by completing this certificate program. I understand and agree to supply Goodwill with any statistics requested to include job changes, wages, promotions, benefits or changes to my , address and phone number. I further agree to allow Goodwill to contact me and my employer on a regular basis. If accepted into the Diesel Certificate Training Program, I attest that all information disclosed on this application is true and correct. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal at any time from the program. Signature Date Please or mail your completed application by May 2, 2016 to: Discover Goodwill Attn: Miriam Yost 1460 Garden of the Gods Road Colorado Springs, CO MYost@DiscoverMyGoodwill.org Phone: Our Business is Changing Lives Page 5 5

8 Eligibility and Suitability Screening I am lawfully present and eligible to work in the United States. I am a Colorado resident. I am 18 years old or older. I am not incarcerated or otherwise unavailable for work. I have a family income at or below 150% the federal poverty level, adjusted for household size (see table below). I am unemployed or employed for no more than twenty hours per week, for at least four consecutive weeks prior to this application. I have actively sought employment through the public workforce system (Registered on Connecting Colorado) Federal Poverty Guidelines Household Size 150% Federal Poverty Level 1 $1,471 2 $1,991 3 $2,511 4 $3,031 5 $3,551 6 $4,071 7 $4,591 8 $5,111 For households of more than 8 members Add $4,160 (monthly +346) for each additional member Countable Income: Wages Salaries Commissions Tips Self-employment Excluded Income: Tax returns Third-party payments for medical care Public assistance (cash or non-cash) Educational loans Emergency assistance payments Veterans aid My household size is: 5/18/2015 Page 1 of 2

9 My monthly household income is: 1. Are you a veteran? 2. Are you 50 years of age or older? 3. Do you have a child support order? 4. Are you currently receiving SNAP (food stamps) or another form of public assistance? 5. Do you have safe, stable housing? 6. Can you get to and from work using reliable transportation? 7. Are you in good health, and able to work? 8. Are you able to pass a drug test? 9. Do you have your GED or HS diploma? 10. Are you excited about getting back to work? TOTAL Y N Printed Name Signature Date 5/18/2015 Page 2 of 2

10 Affidavit of Lawful Presence in United States I,, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen, or I am a Permanent Resident of the United States, or l am lawfully present in the United States pursuant to Federal Law, according to the following type of authorization: I understand that this sworn statement is required by law because I have applied a public benefit. I understand that Colorado state law requires me to provide one of the following forms of proof that I am lawfully present in the United States prior to receipt of this benefit (please place a check next to the document you have offered as proof): A valid Colorado Driver License (includes only a current driver s license: minor driver s license: probationary driver s license, a commercial driver s license, restricted driver s license; instruction permit, or identification card) a valid Colorado identification card, or U.S. military card or military dependent s identification card, or U.S. Coast Guard merchant Mariner Card, or Native American Tribal Document. Out-of-state issued photo driver s license or photo identification card, photo driver s permit expired one year or less. In addition to the four types of identification listed above, the following types of identification will be accepted. Certificate verifying naturalized status issued by an authorized agency of the United States bearing Applicant s intact photograph impressed with the raised embossed seal of the issuing agency. Certificate verifying United States citizenship issued by an authorized agency of the United States bearing Applicant s intact photograph impressed with the raised embossed seal of the issuing agency. 5/18/2015 Page 1 of 2

11 Valid driver s license or ID card bearing applicant s photograph issued by a lawful presence state. All states and the District of Columbia are lawful presence states, with the exception of: Hawaii, Illinois, Maryland, Nebraska, New Mexico, Utah, and Washington. If on the face of the license or ID card presented it says that it is an Enhanced driver s license or ID card, then it is to be accepted as a lawful presence document. Valid immigration documents demonstrating Lawful Presence and verified through the Systematic Alien Verification for Entitlements, administered by the United States Citizenship and Immigration Services of the Department of Homeland Security. Valid immigration documents are as follows: Unexpired Foreign Passport bearing an unexpired "Processed for I-551" stamp or with an attached unexpired "Temporary I-551" visa. Unexpired Foreign Passport accompanied by an "I-94" indicating a specific future "until" date. "I-94" with refugee or asylum status. Unexpired "Resident Alien" card, "Permanent Resident" card, "Temporary Resident" card, or "Employment Authorization" card. l further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute and it shall constitute a separate criminal offense each time a public benefit is received. Furthe1more, I understand it is unlawful for me to offer, use or attempt to offer or use any evidence of my identification where such identification is false, fraudulent or incorrect in any manner or way, or which misrepresents me, or which does not belong to me, or which is altered, forged, defaced, or Signature Date 5/18/2015 Page 2 of 2

12 PPWFC Checklist Application packet Be sure to complete all requested information and sign each page that requires your signature. Application must be returned within 10 working days to avoid document expiration Colorado Driver s license or state ID card Proof of residency, i.e. current utility bill, rental agreement or letter from the person providing you housing (if address is not the same on License/ID) Social Security Card (signed) or U.S. Passport or INS Form Proof of Selective Service (if male, born on or after Jan. 1, 1960) Proof of Food Stamps/TANF eligibility (If Applicable) DD 214, Member 4 copy (if a Veteran) Proof of disability (if applicable) Current IEP (within the last year) signed by a school official, or a statement from physician or State Division of Vocational Rehabilitation verifying that disability is a barrier to employment Proof of income of all family members living with you for the six months prior to application date If you have a documented disability, amount of family income must be entered on application, but you only need to show proof of your income Pay stubs, or employer s statement documenting income for the time frame needed are acceptable Proof of income is not needed if you can provide documentation from the Department of Human Services verifying that you are receiving Food Stamps, SNAP or TANF Proof of family size (This may be Social Security Cards or income tax statements) Proof of school status Associates Degree or higher, High School diploma, GED, IEP, withdrawal letter, etc. If currently enrolled, current transcript is required