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Online Application for Services

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  • Contact Information

  • Alternate Contacts

    List two individuals who know how to reach you. Select friends or family members you have known for more than 5 years.
  • Demographic Data

  • Employment

  • Education

  • Please enter a number from 1 to 12.
    Enter a number 1-12
  • List any degrees/certificates received
  • Goals

    Check as many as you would like
  • Public Assistance

    Are you receiving, or in the past 6 months have received, the following:
    (Mark "Yes" if you are a member of a family that is receiving, or in the past 6 months has received public assistance)
  • Barriers to Employment

    Check all that apply
    Check all that apply
    Check all that apply
    Check all that apply
  • Financial

    Complete the following table. Include all of the individuals in your household.
  • NameRelationship to YouAgeGross Income (past 6 months)Income Source 
    Included as Family Income
    • Wages/Tips/Salary/Commissions
    • Self-Employment
    • Railroad Retirement
    • Strike Benefits
    • Workers’ Compensation
    • Training Stipends
    • Alimony
    • Private Pensions
    • Government Employee Pensions
    • Military Retirement Pay
    • State Disability Insurance*
    • Scholarships (not needs-based)
    • California Promise Grant – AB19
    • Gambling or Lottery Winnings
    • Severance Pay
    • Terminal Leave Pay
    • Social Security Disability Insurance*
    • Wages from CA Conservation Corps
    • Unemployment Insurance
    • Child Support Payments
    • Social Security Old Age Insurance
    • *see confidential questionnaire
    Excluded from Family Income
    • Needs-based Public Assistance
    • TANF, SNAP, SSI, RCA, GA
    • Pell Grants
    • Needs-based Scholarships
    • Loans
    • California College Promise Grant
    • Veteran Benefits
    • Income from Active Military Duty
    • Capital Gains
    • Bank Withdrawals
    • Sale of House/Car/Property
    • Tax Refunds
    • Gifts
    • Lump-sum Inheritances
    • One-time Insurance Payment
    • Insurance Compensation for Injury
    • Non-cash Benefits from Employer
    • Medicare/Medicaid
  • Confidential Health/Medical Information

    Check all that apply
    Includes Single Pregnant Women
  • Voluntary Media Release

    I consent to the use of my quotes and photographs. I grant Golden Sierra Job Training Agency the right to edit and use such products for the purpose of creating a participant testimonial for use in print and online media. I hereby release Golden Sierra Job Training Agency and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
  • Release of Information

  • This release is a voluntary consent that allows Golden Sierra Job Training Agency to make employment inquiries, obtain records, and/or enter into discussions with other organizations. I understand the information released will be used in order to assess, plan, and facilitate the delivery of services for my benefit. I hereby authorize my training provider to release academic records such as attendance, grade reports, and graduation status. In addition, I give permission to Golden Sierra Job Training Agency to contact my current and former employers in order to verify my employment status (i.e. start date, job title, hourly wage, and hours per week). This release will expire 3 years from the date of signature. I hereby certify that I have read and received a copy of this release.
  • Certification

  • I certify that the information provided in this questionnaire is true and correct. I am aware that this information will be used to help determine my eligibility for career and training services. I understand eligibility for services does not constitute an entitlement to services.
  • This field is for validation purposes and should be left unchanged.

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Are You A:

Job Seeker Employer

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I am a Job Seeker Employer

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  • This field is for validation purposes and should be left unchanged.

Golden Sierra
Administrative Office
115 Ascot Drive, Ste. 140 Roseville, CA 95661 • MAP
Phone (916) 746-7722 • Fax (916) 771-2144

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