22-10282 IBM Skillsbuild Training Program Intake Application

IBM SKILLSBUILD TRAINING PROGRAM INTAKE APPLICATION
WHAT IS THE IBM SKILLSBUILD PILOT TRAINING PROGRAM?
The IBM SkillsBuild Program is an IBM-sponsored training program administered by VA to provide no-cost virtual Information
Technology (IT) training. SkillsBuild is a no-cost online learning platform that provides adult learners with the opportunity to gain or
improve IT skills that meet the needs of employers in the High-Technology industry. VA will provide the opportunity for veterans,
service members, and their families to access no-cost, self-paced, virtual training and credentials in Cybersecurity and Data Analytics.
This virtual training in the field of Cybersecurity and Data Analytics is an enhanced resource for veterans, transitioning service
members and other military-affiliated individuals who are seeking job training and credentials to pursue a career in Technology.

HOW DO I QUALIFY TO MEET THE CRITERIA TO PARTICIPATE?
APPLICANT INTERESTED IN PARTICIPATING IN THE SKILLSBUILD TRAINING PROGRAM MUST MEET THE
FOLLOWING INTAKE AND REGISTRATION REQUIREMENTS/CRITERIA:
Intake Eligibility Criteria:
• Applicant must be a veteran, service member, spouse, children, or caregiver who has previous or current entitlement under the
GI Bill program.
Intake Registration Requirement:
• Registration is on a first-come, first-served basis.

WHERE DO I SEND IN MY COMPLETED APPLICATION?
When completed, this application can be submitted electronically via E-mail.
• Submit electronically via E-mail to: vettecpartner@va.gov
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act
of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., VA sends educational forms or letters with a veteran's identifying information to the
veteran's school or training establishment to (1) assist the veteran in the completion of claims forms or (2) VA obtains further information as may be necessary from the
school for VA to properly process the veteran's education claim or to monitor his or her progress during training) as identified in the VA system of records,
58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your response is
required to obtain or retain benefits under this cost-free IBM Skillsbuild Cybersecurity Training Program. While you do not have to respond, VA cannot consider you
approved to participate until we receive this information per (38 U.S.C. 3452(b) and 3501(a)). Your responses are confidential (38 U.S.C. 5701). Information submitted
is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine your eligibility to receive VA approval to participate in the cost-free VA IBM Sponsored
Skillsbuild Cybersecurity Training Program. We cannot provide you any education benefits available under this program until we receive this information (38 U.S.C.
5101). We estimate that you will need an average of 10 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor
a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-888-GIBILL-1 (1-800-442-4551) to get information on where to send comments or suggestions about this form. If you are hearing impaired, call 1-888-829-4833.

VA FORM
XXXXXX

22-10282

Page 1

OMB Approved Number 2900-0922
Respondent Burden: 10 Minutes
Expiration Date: XXXXXXXXXX

IBM SKILLSBUILD TRAINING PROGRAM INTAKE APPLICATION
IMPORTANT: Complete this application to apply for VA Approval to participate in the IBM SkillsBuild Training Program. (This form must be completed in its
entirety.)

PART I - APPLICANT INFORMATION
1. NAME (First, Middle, Last)

2. SEX OF APPLICANT (How would you describe your gender?)
MALE

FEMALE

PREFER NOT TO SAY

TRANSGENDER MAN

TRANSGENDER WOMAN

NON-BINARY/THIRD GENDER

OTHER:
4. E-MAIL ADDRESS (Required)

3. SOCIAL SECURITY NUMBER OF APPLICANT

(Please provide only the last four digits)

XXX - XX 5. MOBILE NUMBER (Include Area Code)

7. TRAINING COHORT DATE

6. HOME NUMBER (Include Area Code)

(MM/DD/YYYY)

8. RACE/ETHNICITY (Please select all that apply for how you describe your race.)
WHITE

BLACK OR AFRICAN AMERICAN

ASIAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

HISPANIC OR LATINO

MIDDLE EASTERN OR NORTH AFRICAN

AMERICAN INDIAN OR ALASKA NATIVE
OTHER:

PART II - MILITARY AFFILIATION
9. SELECT MILITARY AFFILIATION
VETERAN

SPOUSE

CHILD

CAREGIVER

ACTIVE DUTY

NATIONAL GUARD

RESERVIST

INDIVIDUAL READY RESERVE

10. ARE YOU CURRENTLY USING OR PREVIOUSLY USED ANY VA EDUCATION BENEFITS?
YES

NO

PART III - SKILLSBUILD PROGRAM CHOSEN
11. WHAT SKILLS/TRAINING PROGRAM WOULD YOU LIKE TO ATTEND? (Please check only one)
CYBERSECURITY - BASIC

CYBERSECURITY - ADVANCED

DATA ANALYTICS - BASICS

DATA ANALYTICS - ADVANCED

OTHER (If "other," please describe):
12. IF APPLYING FOR AN ADVANCED COURSE, PLEASE DESCRIBE YOUR PREVIOUS TRAINING OR EXPERIENCE IN THE SUBJECT AREA AND CHECK ONE
OF THE BOXES BELOW: (Comment)

BEGINNER

INTERMEDIATE

13A. ARE YOU CURRENTLY EMPLOYED?

EXPERT
13B. ARE YOU CURRENTLY WORKING IN THE HIGH TECHNOLOGY INDUSTRY?

YES

COMPUTER PROGRAMMING

DATA PROCESSING

NO (If "No," skip to Question 13D.)

INFORMATION SCIENCES

MEDIA APPLICATION

COMPUTER SOFTWARE

13C. WHAT IS YOUR CURRENT SALARY RANGE?
<$20,000

$20,001-$35,000

$35,001-$50,000

$50,001-$75,000

>$75,000

13D. WHAT IS YOUR HIGHEST LEVEL OF EDUCATION? (High School, Bachelors, etc.)

14. PLEASE CHECK THE BOX BELOW PROVIDING YOUR COMPLIANCE TO SELF ATTESTING TO THE FOLLOWING CERTIFICATION STATEMENT.

By checking this box, I CERTIFY THAT all the information I have provided is true and correct to the best of my knowledge and belief
and I authorize the release of my answers to the above questions to the Department of Veterans Affairs (VA). I understand that by
submitting this application, I am making a statement to the government for the purposes of obtaining federal benefits. Section 1001 of
Title 18 of the U.S. Code makes it a criminal offense for any person to knowingly and willfully make false or fraudulent statements to any
department or agency of the United States Government.
VA FORM
XXXXXX

22-10282

Page 2