Form BIA 8205 BIA 8205 Application for Job Placement and/or Training Assistance

Form BIA 8205 U. S. DEPARTMENT OF THE INTERIOR OMB No. 1076-0062

Rev 01/2004 BUREAU OF INDIAN AFFAIRS Exp. Date03/31/2011

Burden: 30 Minutes

APPLICATION FOR JOB PLACEMENT AND/OR TRAINING ASSISTANCE

INFORMATION RECORD Social Security No. - -

Name ( Last, First, Middle Initial )			Mailing Address:			Date of Birth: Telephone No. ( )
Veteran Yes No	Marital Status Widowed Married Single Separated Divorced			___Others in Household, non-dependent Explain:		Number of Dependents Dependents Children in School
Services Applying for: ____Job Placement (JP) ____Job Training (JT) ____Other		Request (Circle) Initial JP Repeat 1 2 3 JT Repeat 1 2			In Case of Emergency Name: Address: Telephone No.
Education: Highest Grade Completed: Schools attended and Date(s):
Type of Training or kind of Job you are interested in: Do You have any physical limitations that would interfere with your training or employment? Yes No If yes, please explain Training or Job Location Desired: For Training: Course No. And Title: School and Address: Do you have income from any source? Yes No If yes, please explain
EMPLOYMENT RECORD: (List your three most important periods of employment, starting with the most recent.) From: To: Employer Name and Address: Job Title: Description of Duties: Reason for Leaving:
From: To: Employer Name and Address: Job Title: Description of Duties: Reason for Leaving:
From: To: Employer Name and Address: Job Title: Description of Duties: Reason for Leaving:

Form BIA 8205 U. S. DEPARTMENT OF THE INTERIOR OMB No. 1076-0062

Rev. 01/2004 BUREAU OF INDIAN AFFAIRS Exp. Date 03/31/2011

Page 2 Burden: 30 Minutes

TO BE INITIALED BY APPLICANT FOR TRAINING ONLY:

I hereby apply to attend the school indicated on this application and agree to follow all rules, regulations and attendance requirements of the school and to the best of my ability will satisfactorily complete the course, which I have selected. I further agree that the funds issued me for training purposes by the Bureau of Indian Affairs will be so used or repayment will be made to the U. S. Government. I understand that if I am eligible for other training funds, such as PELL Grant, etc., this will be included when computing my financial aid package and I agree to use those funds for the purpose intended. I authorize the school to release grade, attendance, and income information to the Bureau of Indian Affairs’ personnel. (Initial)

PAPERWORK REDUCTION ACT AND PRIVACY ACT STATEMENT:

Paperwork Reduction Act Notice of 1995 (5 C.F.R. Part 1320): This information is being collected to determine the eligibility for Job Placement & Training services. Response to this request is required to obtain financial assistance. An agency may not collect or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control Number for this collection is 1076-0062.

Burden Estimate Statement: Public reporting burden for this form is estimated to average 30 minutes per response. Send comments regarding the burden estimate or aspects such as utility of information or relatedness to mission of BIA, to Information Collection Clearance Officer, 1849 C Street, NW, MS-4141, Washington, DC 20240.

1. The authority for solicitation of the information on this form is 25 U.S.C. 13 (42 Stat. 208) and P.L. 84-959 (70 Stat. 986) as amended by P.L. 88-230 (77 Stat. 471, 25 U.S.C. 309)

2. Disclosure of the requested information by the applicant is voluntary, but required to obtain a benefit.

3. The purpose of this information collection is to determine your eligibility for services.

4. The routine use of this information by the BIA and school counselors is to evaluate your request and to assist you before and during your Job Placement & Training activities. After completion of Training, or a Job Placement, parts or all of the information in your application will be provided to employers who are considering you for employment. The application will be used in a routine manner by counselors working with you who need background information, and by those persons involved in financial control who need budgeting information contained in the application.

5. Failure to provide requested information may result in a delay (or denial) in receiving the training or job placement assistance you are seeking.

I have read the above statement. I hereby provide the required information and authorize the use of such information to the extent of the uses specified in the statement.

______________________________________________

(Applicant’s Signature) (Date) (Interviewer’s Signature) (Date)

FOR AGENCY USE

I certify that Is Degree of Indian blood, and a member of the ________________________________Tribe and is/is not eligible for training or job placement services. Individual is serviced by ( Agency) of ( Region).

Recommended by: Approved:___________ _________________________ Title________ (Agency Superintendent)

If required, Regional Action taken: Approved Disapproved Date:_________________

(Regional Director)__________________________________

DISPOSITION OF THIS CASE: Training completed on (date )

Trainee is currently a permanent employee and has remained employed for at least 90 days YES/NO.

Earnings: $_____________PRE-Job Placement & Training Service $_____________POST-Job Placement &Training Service

Upon training completion, Trainee received; ___Certificate, ___Degree (2yr)

__Trainee dropped out (reason):

Case worker’s Signature and Date