GAP Application

=Required

Part A. Participant Information

First Name:

Middle Initial:

Last Name:

Previous/Maiden Name:

Birthdate (mm/dd/yyyy):

Email:

Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Do you have a valid driver's license?

Yes No

Race/Ethnicity

White (non-Hispanic) Asian or Pacific Islander Hispanic Native American Black (non-Hispanic) Two or More Races

Are you a citizen of the United States?

Yes No

Are you a Nebraska resident as provided in Nev. Rev. Stat. § 85‐502?

Yes No

What type of employment are you seeking?

Full-time Part-time

When are you available to attend training?

Day Night Both

Part B. Education

Have you received your high school diploma?

Yes No

Have you attended college or any training programs?

Yes No

Are you currently receiving funding for education from any other source or organization?

Yes No

Part C. Employment

Are you currently employed?

Yes No

Please list all jobs (up to three), activities and other experiences, including volunteer work, part-time employment, military service, and self-employment for the past five years, beginning with your most recent position first.

Employer 1

Please complete the following information.

Employer Name:

Job Title/Position:

Start Date:

End Date:

Additional Employment
Add another Employer

Are you currently receiving unemployment benefits?

Yes No

Do you have a current and up-do-date resume?

Yes No

Part D. Income Qualification - Total Household Gross Income

Part E. Program Interest & Desired Outcome

What training program are you interested in?

Please describe your financial need and why you are requesting GAP assistance?

What are your expectations and goals for next year?

Why should you be awarded this assistance?

Part F. Signature & Understanding

I certify (promise) that all information on this application is true and correct. I understand that this information may be verified. I also understand that I may be asked to provide documentation to support information provided on this portion of the Nebraska Community College Assistance Application.
I understand that eligibility for Gap assistance shall not be construed to guarantee enrollment in any Gap program.
I understand this application is valid for six months from the date of signature on this application and that I cannot receive Gap assistance for more than one program.
I understand that if it is determined that funding for my participation in this program is available from any other public or private funding source, my application will be denied.
I am aware that if I purposely give false information, I may lose my Gap assistance and I may be prosecuted under any applicable State and Federal laws.
I grant permission to Southeast Community College to release information about my participation in the Gap Assistance Program to the Nebraska Postsecondary Coordinating Commission.

By checking this box you understand and agree to the above.

Leave this field blank

You will receive a confirmation email after your submission is received.

Employer 1

Employer 2

Employer 3

Your Income

Spouse Income (if applicable)