Workforce Grant Application

Name(Required)

First Middle Last

Gender(Required)

Male

Female

SSN(Required)

Email(Required)

Student ID (If Known)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone Contact(Required)

Cell Phone

Date of Birth(Required)

Veteran

Yes

If yes, then please list branch and date of active status:

Residency(Required)

US Citizen since birth

Naturalized: Became US Citizen after birth

Not a US Citizen/Country of Citizenship

Ethnic Group

White

Black/African American

American Indian

Hispanic/Latino

Native Hawaiian/Pacific Islander

Asian

Non-specific

Emergency Contact

First Last

Relationship

Emergency Contact Phone

Employer Phone

My Employer is:

Paying the course registration fee

Reimbursing me for the course registration fee

Neither -- I am responsible for the course registration fee

My course is:

Directly related to my employment

Not related to my employment

Beneficial to acquiring new job skills/certifications

Course Registration(Required)

Fall

Spring

Course Year(Required)

Course Title(Required)

Course Number and Section

Course Date

Course End Date

Course Fee (If Known)

Method of Payment

Credit Card/Visa, Mastercard Only

Bill My Employer

Check or Money Order

If paying by credit card, what is your contact number to reach you?

If you are paying with check or money order, please mail to:

Attn: Workforce Development 3441 Mountain Empire Road, Big Stone Gap, VA 24219

If employer is paying, please mail PO or Letter of Authorization to:

Attn: Workforce Development 3441 Mountain Empire Road, Big Stone Gap, VA 24219

VCEDA/Non-Credit Financial Aid Application

Please email copies of the following eligibility documents required for qualification for Continuing Education Financial Aid to workforce@mecc.edu. Citizenship Status, Proof of Virginia Residency & Age Verification

Compliance with Military Selective Service Act (male students only)

Yes

I am in compliance with the Selective Service Act requirements.

Highest Level of Education (select all that apply)(Required)

No High School Diploma/GED

GED

High School Graduate

Some college no degree

Associate’s Degree

Bachelor’s Degree

Master’s Degree

Doctoral Degree

Are you currently enrolled in an Associate or Bachelor’s degree program?

Yes

Have you ever received an industry credential?

Yes

Are you eligible for other tuition assistance benefits?

Are you a veteran who is eligible for GI Bill funding?

Yes

Are you currently employed?

Yes

Are you or will you be receiving any other tuition assistance for this program from other sources?

Yes

Are you eligible for SNAP (Supplemental Nutrition Assistance Program) or TANF (Temporary Assistance for Needy Families)?

Yes

Household Income

Is anyone claiming you as a dependent on their tax return?

Yes

Household Income (If hourly – Rate of Pay per hour X Hours Worked per year)

Number of persons in family/household

Applicant submitted Tax Transcript verifying household income.

Yes

Additional Information for Clarification:

Domicile Determination

Mark the domicile category that applies to you.

1. I am age 24 or older and want to claim eligibility based on my own domicile or I am under the age of 24 and want to claim eligibility based on my own domicile for the following reason(s):

Please check

Please all that apply

I am a veteran or active-duty member of the U.S. Armed forces

Both of my parents are deceased, and I have no adoptive or legal guardian.

I have legal dependents other than my spouse.

I am financially self-sufficient.

I am a ward of the court or was a ward of the court until age 18.

I have a bachelor’s degree and I am working on a graduate degree.

I am married.

2. Spouse: I am age 24 or older and want to claim eligibility for in-state tuition based on my spouse’s domicile, Spouse: I am under age 24 and I want to claim eligibility for in-state tuition based on my spouse’s domicile, Parent: I am under age 24 and my parents provide more than half of my financial support and/or claim me as a dependent for tax purposes, or Legal Guardian: I am under age 24 and my courtappointed legal guardian provides more than half of my financial support and/or claims me as a dependent for tax purposes

Please Check

You may be required to supply “clear and convincing evidence” of your status.

Applicant’s Information

Are you a permanent resident?

Yes

What is your “A Number”?

What is your immigration status?

Are you on active duty in the U.S. Armed Forces?

Yes

Is Virginia listed as the Tax State on your Leave and Earning Statement?

Yes

Date of Entry

Official Duty Station

Reporting Date:

Duration of Orders

Are you the dependent of an active-duty member in the U.S. Armed Forces?

Yes

Is Virginia listed as the Tax State on your Leave and Earning Statement?

Yes

Date of Entry

Official Duty Station

Reporting Date:

Duration of Orders

Are you retired from the U.S. Armed Forces?

Yes

Were you discharged from the U.S. Armed Forces?

Yes

Date of discharge/retirement

Tax State on LES prior to discharge/retirement:

Are you the dependent of someone retired from the U.S. Armed Forces?

Yes

Are you the dependent of someone discharged from the U.S. Armed Forces?

Yes

Date of discharge/retirement:

Tax State on LES prior to discharge/retirement:

Have you lived in Virginia for the last 12 months?

Yes

From Date

To Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For the last 12 months, which of the following applies to you:

Paid Virginia income taxes on all earned income

Filed as a resident in another state

Filed as a resident in Virginia and as a non-resident in another state

Was a resident in a state without income tax

Had no taxable income

What state?

For the past twelve months, have you lived out-of-state, worked in Virginia, and paid Virginia income taxes on at least $14,500 of earned income?

Yes

What state?

For the past 12 months, have you:

• Held a Virginia Driver’s License or Virginia DMV ID?

Yes

Have you held a Driver’s License or DMV ID to any other state?

Yes

What state

• Owned or operated a motor vehicle registered in Virginia?

Yes

Have you owned or operated a motor vehicle registered in any other state?

Yes

What state?

• Been Registered to vote in Virginia?

Yes

Have you been registered to vote in any other state?

Yes

What state?

Parent, Legal Guardian, or Spouse’s Information

Provide the name of the person upon whom you are basing your domicile:

First Middle Last

Using the above person’s information, answer the questions below

Is the person above a U.S. Citizen?

Yes

Is he/she a permanent resident?

Yes

What is his/her “A number”?

What is his/her immigration status?

Is the above person on active duty in the U.S. Armed Forces?

Yes

Is Virginia listed as the Tax State on his/her Leave and Earning Statement?

Yes

Date of Entry

Reporting Date

Official Duty Station

Durartion of Orders

Is the above person retired from the U.S. Armed Forces?

Yes

Is the above person discharged from the U.S. Armed Forces?

Yes

Date of discharge/retirement

Tax State on LES prior to discharge/retirement

Is the person above a dependent of someone retired from the U.S. Armed Forces?

Yes

Is the person above a dependent of someone discharged from the U.S. Armed Forces?

Yes

Date of discharge/retirement

Tax State on LES prior to discharge/retirement

Has the above person lived in Virginia for the last 12 months?

Yes

From Date

To Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

From Date

To Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For the last 12 months, which of the following applies to the above person:

Paid Virginia income taxes on all earned income

Filed as a resident in another state

Filed as a resident in Virginia and as a non-resident in another state

Was a resident in a state without income tax

Had no taxable income

What state?

For the past twelve months, has the above person lived out-ofstate, worked in Virginia, and paid Virginia income taxes on at least $14,500 of earned income?

Yes

What state?

For the past 12 months, has the above person:

• Has above person held a Virginia Driver’s License or Virginia DMV ID?

Yes

Has the above person held a Driver’s License or DMV ID to any other state?

Yes

What state?

• Has above person owned or operated a motor vehicle registered in Virginia?

Yes

Has the above person owned or operated a motor vehicle registered in any other state?

Yes

What state?

• Has above person been registered to vote in Virginia?

Yes

What state?

Assumption of The Risk

I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been informed of the general nature of the risks involved in this activity, including, but not limited to personal injury and loss of personal property. I understand that in the event of accident or injury, personal judgment may be required by Mountain Empire Community College regarding what actions should be taken on my behalf. Nevertheless, I acknowledge that Mountain Empire Community College may not legally owe me a duty to take any action on my behalf. I also understand that it is my responsibility to secure personal health insurance in advance, if desired, and to take into account my personal health and physical condition. I further agree to abide by any and all specific requests by Mountain Empire Community College for my safety or the safety of others, as well as any and all of Mountain Empire Community College’s rules and policies applicable to all activities related to this program. I understand that the College reserves the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others. In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby agree that I am responsible for any resulting personal injury, damage to or loss of my property which may occur as a result of my participation or arising out of my participation in this program, unless any such personal injury, damage to or loss of my property is directly due to the negligence of Mountain Empire Community College. I understand that this Assumption of Risk form will remain in effect during any of my subsequent visits and program-related activities, unless a specific revocation of this document is filed in writing with the Dean of Student Services, at which time my visits to or participation in the program will cease. I represent that I am 18 years of age or older and legally capable of entering into this agreement.

FastForward

If I do not successfully complete the course by earning an “S” grade within thirty (30) days of the course end date, I agree to pay an additional 1/3 of the total course cost to: Mountain Empire Community College. If I earn an “S” grade within thirty (30) days of the program end date, I will not have any further financial obligations to the College for this course. If I must pay an additional amount, I understand and agree to the following terms: (A) I agree that I must pay all the money I owe to the College, although there may be reasons under the law that would reduce the amount that I owe. I also agree not to claim that I do not owe the money to the College. This means that homestead and all other exemptions, presentations, demand, protest and notice of dishonor are hereby waived by the undersigned. (B) If the College does not receive payment within the timeframe noted in the College policy, I understand and agree that the Commonwealth will take all actions, including debt set‐off, to collect the money I owe to the College. (C) I also agree to pay all associated collection costs and/or attorney’s fees if necessary to collect the money I owe to the College.

I understand in the case where the College has an agreement with my employer covering my specific participation in this New Economy Workforce Credential Grant Program (WCG) course, I will not be responsible for the additional 1/3 of the total course cost should I not successfully complete the course by earning an “S” grade within thirty (30) days of the course end date. I acknowledge and understand that I may owe my employer the additional 1/3 of the total course cost under a separate agreement or other arrangement, if I do not successfully complete the course. I further acknowledge and understand that the College will bill my employer the additional 1/3 of the total cost if I do not successfully complete the course by earning an “S” grade within thirty (30) days of the course end date. Accordingly, I hereby consent to the disclosure of my final grade to my employer if it is necessary for the College to receive the final 1/3 of the total course cost or for any other legitimate educational reason related to the WCG course.

(1) I understand the purpose of the WCG is to financially assist me to gain the knowledge AND the applicable industry recognized credential or licensure. Therefore, I agree to seek the applicable credential or licensure associated with my program whether it is incorporated into the program cost or requires me to obtain the credential or licensure at an additional cost. I also agree to provide proof of my satisfactory completion of that credential or licensure to the College. (2) I understand that my social security number is required in order to maintain enrollment in this class. My social security number is being collected in accordance with federal and state law, and to claim the tax refund and other applicable state refunds and payments in cases where I must pay the College; for debtor information and skip‐tracing; and to track and report the number of students who attain noncredit workforce credentials and other outcomes under this WCG. (3) I am 18 years or older. If I am under 18 years old, a parent or legal guardian has completed this agreement on my behalf. (4) By reading and responding to the following questions, I will agree to the above terms and conditions of this agreement. I understand that I may sign this agreement by hand and may do so by contacting the College. (5) I agree to the withdrawal, refund, repeat, completion, and non‐completion procedures at the College. (6) I understand that I may file a complaint(s) using the procedures established by the College. (7) Virginia "domicile" means that you have lived in Virginia and intended to stay here indefinitely for at least one year prior to the date of this application. I understand that I must be domiciled in Virginia to receive the discount applied to this course. If I do not have domicile in Virginia, I will pay the full cost of the course, which is equal to three times the amount paid at initial enrollment. (8) I have not previously enrolled in and successfully passed this training program at a Virginia Community College. If I have previously enrolled in and successfully passed this training program at a Virginia Community College, I understand that I am not eligible to receive WCG funding for this training program and agree to pay an additional 2/3 of the total course cost to the community college where I am now enrolling.

I understand that I must submit the following documents via email to workforce@mecc.edu or provide a copy to MECC’s Workforce Solutions at 3441 Mountain Empire Road, Big Stone Gap, VA 24219.(Required)

Most Recent Federal Income Tax Return or W-2’s , All documented forms of income (i.e. SNAP Card, alimony, etc.) If applicable. Proof of citizenship (ID and Social Security Card) If applicable. Driver's License

Signature

Date

Signature of Parent/Legal Guardian (If under 24 years old) or Spouse

Date