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If working part-time or working in a job that does not provide comparable responsibility and
pay to a previous job, or working as a contractor: Current Pay Stub.
Step 3: After you have submitted your application, a Career Specialist will contact you for an
appointment.
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
CONTACT INFORMATION
Name: Application Date:
Address: Email:
VETERAN STATUS
BACKGROUND INFORMATION
Date of Birth: ________________________ Are you currently receiving any public assistance (TANF,
SNAP, SSI)? Yes No
Sex: Male Female
Are you currently receiving Reemployment Assistance
Citizenship: (RA)? Yes No
If so, how many weeks have you received RA in the last
U.S. Citizen
27 months? __________
Lawful Permanent Resident
Other immigrant authorized to work in the U.S.
If not working now, what was the end date of your most
Race: recent employment? _______________
African American/Black If not working now, how many weeks have you been
American Indian/Alaskan Native unemployed?
Asian 27 weeks consecutive or more
Native Hawaiian/Other Pacific Islander Less than 27 weeks
Caucasian/White
Other What is your most recent job title?
__________________________________________
Number of family members in household: _________
Are you of Hispanic origin? Yes No
Number of dependents under 18: _______________
Do you have a disability that makes it difficult for you Applicants Annual Income: ____________________
to work? Yes No Annual Family Income: _______________________
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
EMPLOYMENT HISTORY
What is your current employment status? What type of business are/were you working in?
EDUCATION INFORMATION
What is your highest level of education? Are you currently enrolled in an educational program?
Yes No
List any degrees and/or certifications achieved below: Dates of degree(s) and/or certification(s):
1.
2.
3.
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
I hereby certify, to the best of my knowledge, the above information is true. I understand the information is subject to verification
and agree to provide such documentation as required. I understand my social security number may be given to other federal,
state and local government and non-government agencies for tracking purposes. The social security number is used to administer
the program, including determining eligibility, attributing the receipt of services, correspondence and participation to my case, as
well as for program reporting purposes. Data will be used for statistical purposes only.
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
FAMILY SIZE:
For use in completing this form the definition of FAMILY SIZE is:
HOUSEHOLD INCOME:
For use in completing this form include each of the following as INCOME:
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
As a participant of CareerSource Capital Region (CSCR) career centers, I hereby authorize the release
of confidential information to the employees, representatives or agents of CSCR. The representatives
of CSCR are authorized by me to obtain information from all references (personal and professional),
employers, public agencies, licensing authorities and educational institutions. This information may
include, but is not limited to, educational records (such as testing scores, attendance information, etc.),
public assistance records and income/employment information.
I hereby give consent for CSCR to engage in verbal, written, facsimile or computerized communication
of information required to verify my eligibility for services, identify services or agencies to assist me,
assess my qualifications to enter a CSCR program, monitor progress while participating in a CSCR
program and to provide employment/educational recommendations and follow-up completion of
training. I hereby waive any and all rights and claims I may have to privacy regarding the employer, its
agents, employees or representatives for seeking, gathering and using such information in the
verification process and all other persons, corporations or organizations, be it Federal, State or Local,
for furnishing such information about me.
I further understand that this release will be effective during the length of my participation, as well
as for one (1) year following completion of the program(s) in order to assist staff with their follow-
up procedures.
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
Gadsden: (850) 875-4040
Leon: (850) 922-0023
Wakulla: (850) 926-0980
Executive Center: (850) 414-6085
Participant Name:
NOTICE OF NONDISCRIMINATION:
CareerSource Capital Region does not discriminate on the basis of race, color, religion, sex, sexual orientation, national
origin, age, disability, marital status, political affiliation or belief, citizenship/status as a lawfully admitted immigrant
authorized to work in the United States, participation in any WIA Title I financially assisted program or activity, or any other
characteristic protected by Federal, State or local law.
Programs funded through CareerSource Capital Region are equal opportunity programs with auxiliary aids and services
available upon request to individuals with disabilities. Persons using TTY/TTD equipment use Florida Relay Service 711.
Disabled individuals may make requests for reasonable accommodations to the CareerSource Capital Region Equal
Opportunity Officer by calling (850) 414-6085, emailing info@careersourcecapitalregion.com or writing to CareerSource
Capital Region, Equal Opportunity Officer, 325 John Knox Road, Atrium Building, Suite 102, Tallahassee, FL 32303.
Any individual with questions or concerns regarding any type of perceived discrimination is encouraged to contact the
CareerSource Capital Region Equal Opportunity Officer. An individual can ask questions, raise concerns and file a
complaint without fear of reprisal or retaliation.
COMPLAINT PROCEDURES:
As a customer/applicant/participant you have the right to file a complaint/grievance if you feel you have been treated
unfairly. If during your participation in any workforce program(s) including Wagner-Peyser (WP), Workforce Investment Act
(WIA), Welfare Transition (WTP), Supplemental Nutrition Assistance Program Employment & Training (SNAP), or any special
grant/project, feel that your rights are being violated due to an act of discrimination based on race, color, religion, sex,
sexual orientation, national origin, age, disability, marital status, political affiliation or belief, citizenship/status as a lawfully
admitted immigrant authorized to work in the United States, participation in any WIA Title I financially assisted program or
activity, or any other characteristic protected by Federal, State or local law, you may file a complaint of discrimination. You
may file a formal written complaint with the Grievance/Complaints Section at the following address (within 180 days of the
occurrence): CareerSource Capital Region, Director of Operations, ATTN: Grievance/Complaint Section, 2525 S. Monroe St,
#3-A, Tallahassee, FL 32301. Unresolved complaints may be sent to the Florida Department of Economic Opportunity,
Office of General Counsel, Caldwell Building- Suite 150, 107 East Madison Street, Tallahassee, Florida 32399-4128.
HEARING PROCEDURE:
Complaints or grievances should be filed in writing and submitted to CareerSource Capital Region. An attempt will be
made to clear up the matter informally within 10 working days (first hearing). If the complaint or grievance is not cleared up
informally, a second hearing shall be held and a decision shall be rendered by CareerSource Capital Region CEO within 60
calendar days from receipt of the complaint or grievance. You will be informed of the date and place and about the hearing
and appeal process. If you are not satisfied with the decision of the CareerSource Capital Region CEO or do not receive a
hearing within 60 calendar days, you may appeal to the Florida Department of Economic Opportunity (DEO) (within 30
days). Grievance/Complaint and Hearing/Appeal Process for WIA, TAA, TANF/WT, and SNAP programs should be filed with
Florida Department of Economic Opportunity, Office of General Counsel, 107 East Madison Street, MSC 110, Tallahassee,
Florida, 32399-4128. Complaint procedures for Wagner-Peyser Employment Services activities (except Migrant Seasonal
An equal opportunity employer/program. Auxiliary aids and services available upon request Disclosure of your social security number is voluntary. It is requested however,
to individuals with disabilities. Persons using TTY/TTD equipment use Florida Relay Service pursuant to Privacy Act of 1974. Social security numbers will be used by
711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
Gadsden: (850) 875-4040
Leon: (850) 922-0023
Wakulla: (850) 926-0980
Executive Center: (850) 414-6085
Farm Worker (MSFW) program may be filed with the Florida Department of Economic Opportunity, Office of One-Stop and
Program Support, Caldwell Building-Suite 105, 107 East Madison Street, Tallahassee, Florida 32399-4133, Attention ES
Complaint Coordinator. MSFW complaints may be filed with the Florida Department of Economic Opportunity, Monitor
Advocate Office, Caldwell Building-Suite 150, 170 East Madison Street, Tallahassee, Florida 32399-4133, Attention: Senior
Monitor Advocate.
Under Florida law, employees or applicants may also choose to file employment complaints with the Florida Commission on
Human Relations. (See Section 760.06, Florida Statutes.) Contact the following entities for discrimination, employment,
health and safety, or Florida Law violations/complaints:
An equal opportunity employer/program. Auxiliary aids and services available upon request Disclosure of your social security number is voluntary. It is requested however,
to individuals with disabilities. Persons using TTY/TTD equipment use Florida Relay Service pursuant to Privacy Act of 1974. Social security numbers will be used by
711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
Gadsden: (850) 875-4040
Leon: (850) 922-0023
Wakulla: (850) 926-0980
Executive Center: (850) 414-6085
I certify that I have read the above statement and understand my rights and responsibilities as outlined:
As a representative of the Workforce System, I verify that the above-signed participant read the above statement of
Grievance/Complaint and Hearing/Appeal procedures and indicated an understanding of the procedures.
An equal opportunity employer/program. Auxiliary aids and services available upon request Disclosure of your social security number is voluntary. It is requested however,
to individuals with disabilities. Persons using TTY/TTD equipment use Florida Relay Service pursuant to Privacy Act of 1974. Social security numbers will be used by
711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
The STEM Ready program requests your permission to share your experiences while participating in
or receiving a benefit from the STEM Ready program. With your permission, there is a possibility that
you may be photographed, videoed, have your voice recorded or comments printed for the purpose
of promoting the program. Your signature below allows STEM Ready, its agents, contracted service
providers and their respective staff, the broadcast media or other persons authorized by STEM Ready
to photograph, videotape, audiotape or print your comments.
Your participation is voluntary and will take place during scheduled hours of a program, event or at a
time that is convenient to you and the organization. Please sign below if you agree to participate. If
you decide not to sign this form, you will not be photographed, videoed, have your voice recorded or
your comments printed during a program or event. Your eligibility or participation in STEM Ready will
not be affected by your decision.
By my signature below, I give my permission for STEM Ready, its agents, contracted service providers
and their respective staff, broadcast or print media to photograph, video record, audio record or print
comments from me. I understand that I will not receive any form of compensation for the use of my
picture, vice or comments. Any photographs, video and audio of me, or comments from me are and
will remain the property of STEM Ready.
I understand that I may revoke my permission at any time by notifying STEM Ready in writing of my
decision to do so.
____________________________________________ _______________________
Participant Signature Date
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
Unemployed
Employed
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004
STEM Ready
APPLICATION FOR PROGRAM PARTICIPATION
_____ To ensure that STEM Ready can provide effective services to all customers, it is very important that
you maintain contact with your Career Specialist on a monthly basis, at minimum.
_____ Any changes in address, phone number, training plan, or employment status must be reported to
your Career Developer.
_____ Each customer will receive individualized services and be actively engaged in the development of
an Individual Training Plan (ITP) and/or an Individual Employment Plan (IEP). Your will receive a
copy of the IEP/ITP and be responsible for completing all tasks as outlined in the IEP/ITP to ensure
success.
_____ At program completion you must provide all documentation necessary to ensure verification of
outcomes resulting from your participation (e.g. school/licensure/certification/etc.).
_____ As part of the STEM Ready federal program requirements, you agree to participate in quarterly
follow-up contact for up to one year after STEM Ready program completion.
_____ Knowingly misusing STEM Ready funds for any reason will result in immediate termination from the
program.
_____ Each customer shall be informed of and provided with a copy of the grievance procedure, and has
the right to file a complaint/grievance as granted by law to all applicants and participants.
An equal opportunity employer/program. Auxiliary aids and services available Disclosure of your social security number is voluntary. It is requested however,
upon request to individuals with disabilities. Persons using TTY/TTD equipment pursuant to Privacy Act of 1974. Social security numbers will be used by
use Florida Relay Service 711. CareerSource Capital Region for the sole purpose of system review to
determine our overall level of efficiency.
SRG-FR-0004