Application for Open Door Funding

Please fill out the information below and look for a follow-up email about the next steps!

Contact Information

The funding source for this scholarship requires we collect certain information to verify eligibility. Please complete the entire application.

First Name

Middle Name

Last Name

Social Security Number

Please write the last 4 digits of your Social Security Number

Primary Address

City

State

Zipcode

Primary Phone

Phone

Demographic Information

Date of Birth

mm/dd/yyyy

What is your current age?

What is your gender?

Male

Female

Did not self-identify

Are you of Hispanic/Latino heritage?

Yes

Are you of Haitian Heritage?

Yes

Are you a U.S. Citizen?

Yes

Are you married?

Married

Single

Are you a single parent? (This includes single pregnant women)

Yes

Are you homeless or living in a shelter?

Yes

Have you registered for Selective Service?

Yes

Not Applicable (females only)

Are you a migrant seasonal farmer?

Yes

Are you an English language learner?

Yes

Who were you referred by?

Please list a person, organization, or write "none"

Veterans and Active Military

Are you a veteran of the U.S. Armed Forces?

Yes

Are you the spouse of a member of the armed forces

Yes

Low Income Eligibility

Please select which foster home situation applies to you

Currently in foster care

Aged out of foster care

Never in foster care

Are you an ex-offender or have you been arrested or convicted of a crime

This includes DUI and DWI charges. Don't be concerned about this disqualifying you. In most cases, being involved in the judicial system can make an applicant eligible.

Yes

Are you a runaway youth?

Yes

Have you or an immediate family member received TANF or cash assistance within the last 6 months?

Yes

Have you or an immediate family member received SSI (supplemental security income) within the last 6 months?

Yes

Have you personally received Supplemental Security Disability Insurance within the last 6 months?

Yes

Are you receiving General Assistance

Yes

Have you or a family member received food stamps within the last 6 months?

Yes

What is your household annual income?

How many family members live in your household?

Are you unlikely to return to a job at self-sufficient wage

Answer yes if you are struggling to find employment that can sustain you.

Yes

Employment History

Are you Currently Working?

Yes

Education History

Are you currently enrolled in school?

Yes

What is the name of the school?

Write none if not enrolled in a school

Have you completed the Free Application for Federal Student Aid (FAFSA) application?

To be eligible for an Open Door scholarship, students must complete the FAFSA. For questions or help in completing the FAFSA, go to https://www.spcollege.edu/financial-aid/askfas

Yes

No (This is required. Please read the instructions above)

Are you receiving or have you been notified you will receive PELL grant monies?

Yes

Unsure

If you are a student at SPC, what is your ID number?

If you are not a current student, please write "none"

Training Program Start Date

What is your highest grade completed? (0-12)

Dislocated Worker Eligibility

Were you laid off/terminated from your last job?

Yes

Unemployment Referred by Status

WPRS (Worker Profiling and Reemployment Services)

REA (Reemployment Eligibility and Assessment)

RESEA (Reemployment Services and Eligibility Assistance)

N/A

Have you attended a Rapid Response Orientation

Yes

Unsure

Are you currently receiving Ra/unemployment benefits?

I am a claimant

I have exhausted my unemployment

I have neither claimed nor exhausted my unemployment

What is the date of your last Ra/unemployment payment?

mm/dd/yyyy. Leave as "N/A" if not applicable to you.

Have you worked or earned wages since exhausting your Ra/unemployment?

Leave as "N/A" if not applicable to you.

Yes

N/A

Have you performed at least 3 job searches where you have submitted applications in person or online?

Yes

Are you a self-employed individual who has lost your employment contract or business earnings due to the economic downturn and has been unable to find employment or replace your business earnings?

Yes

Are you an individual who has been providing unpaid services to a family member in the house while being dependent on income from another family member?

Yes

N/A

Worke Rights under Federal Law

Worker Rights under Federal Law

Americans with Disabilities Act

Ask for a Disability Navigator – located in the CSPIN offices. The ADA information line: 800-514-0301 (voice) 800-514-0383 (TDD)

Fair Labor Standards Act FLSA general information: (202) 606-1800

TTY: (202) 606-2582

Civil Rights Laws Local Contact: Steve Meier: (727) 608-1709

smeier@careersourcepinellas.com

State Contact: Veronica Owens EEOC (850) 921-3205

Equal Pay Act Local Contact: Steve Meier: (727) 608-1709

smeier@careersoucepinellas.com

State Contact: Veronica Owens EEOC (850) 921-3205

PRIVACY ACT STATEMENT:

Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your social security number is mandatory. Social security numbers will be used by the Agency for program administration including verification purposes, distinguishing one individual from another, and for tracking and reporting purposes.

Final Steps

After submitting the application, you will receive an email within 24 hours explaining the next steps.

By entering my name below, I hereby give permission for CareerSource Pinellas and St. Petersburg College to obtain and/or disclose my past, present, and future information or records that may be needed for eligibility determination, monitoring and follow-up purposes. This information may include, but shall not be limited to: school records, grade records, attendance records, employment information, medical records, public assistance records, employment information and vocational rehabilitation assessment or evaluation tools. A photocopy/facsimile of this signed consent form may be used to obtain/release information authorized by signature on this form. It is also my understanding that any information obtained by the above organization will be held in strict confidence. I understand that I may revoke this consent at any time by providing a written statement indicating that my consent to the release of information is no longer given to the party(ies) previously granted permission.

Please type your full first and last name below as a signature

Once you press "Submit" you will be taken to a DocuSign website to sign a consent form for SPC and CareerSource. After you sign the document, keep an eye out for a follow-up email with mandatory next steps.

For minors under the age of 18, you will sign a separate document with your legal guardian.

I will sign the consent form and look for the follow-up email.

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