Career Pathways Initiative Program Application

Tuesday, April 23, 2024

Career Pathways Initiative Program

Please read the following before submitting this application:

All applicants must have a goal of employment in accordance with Arkansas Act 514.
Due to the high volume of applications received, priority is given to current TEA participants and students enrolled in high-wage/high-demand areas of study.

1 Personal Information
2 Children
3 Status/Benefits
4 Education
5 Employment
6 Submit Application

The following information is requested to determine eligibility to participate in the Career Pathways Initiative (CPI). You will be contacted with more information about the program if you appear eligible to participate.

Personal Information

Last Name:

First Name:

Middle Name:

Maiden:

UA-PTC E-mail Address:

Personal E-mail Address:

UA-PTC Student ID:

Date of Birth:

Physical Address:

Apartment Number:

Mailing Address:

*Skip, if your physical address is the same as your mailing address.

Apartment Number:

Cell Phone:

Home Phone:

County:

Emergency Contact Name:

Emergency Contact Number:

1 Personal Information
2 Children
3 Status/Benefits
4 Education
5 Employment
6 Submit Application

Children

Do you have any children, 21 years old or younger?

Yes

If you answered yes, please complete the following:

1. Child Name:

Age:

School or Childcare:

2. Child Name:

Age:

School or Childcare:

3. Child Name:

Age:

School or Childcare:

1 Personal Information
2 Children
3 Status/Benefits
4 Education
5 Employment
6 Submit Application

Status/Benefits

Race:

Asian/Pacific Islander

Black (Non-Hispanic Origin)

Hispanic

American Indian/Alaska

Non-resident Alien

White (Non-Hispanic Origin)

Other

Marital Status:

Single

Married

Divorced

Legally Separated

Gender:

Male

Female

Unknown

Other Gender

Check all that you currently receive:

Food SNAP

Medicaid (including ARKids)

TEA / Work Pays

SSI/SSD

Unemployed

Other Income

Housing status:

Rent

Mortgage

HUD

Own

Other

How do you pay your bills and support your family?

Self

Boyfriend/Girlfriend

Spouse

Family/Friend

Other

1 Personal Information
2 Children
3 Status/Benefits
4 Education
5 Employment
6 Submit Application

Education

High School:

Address:

From and To:

Did you graduate?

Yes

If yes, when?

1. GED:

Address:

From and To:

Did you graduate?

Yes

If yes, when?

Degree:

2. GED:

Address:

From and To:

Did you graduate?

Yes

If yes, when?

Degree:

3. GED:

Address:

From and To:

Did you graduate?

Yes

If yes, when?

Degree:

Are you currently enrolled in classes?

Yes

If yes, where?

Program Major:

What term do you plan to enroll at UA - Pulaski Tech?

Fall

Spring

Summer I

Summer II

What degree and or certificate do you plan to complete?

Associate’s Degree

Technical Certificate

Certificate of Proficiency

GED

Arkansas Career Readiness Certificate

Undecided

Have you applied for Financial Aid (Pell Grant)?

Yes

Do you receive student loans?

Yes

Are you in default on a student loan?

Yes

Do you owe money to another college?

Yes

Please list any additional sources of assistance you will be receiving to help you attend college (Arkansas Rehabilitation Services, Single Parent Scholarship, Arkansas Challenge, etc.):

What is your ultimate goal after completing your education at UA - Pulaski Tech?

Immediate employment in a high demand/high wage career

Self-employed/Open own business

I do not plan to seek immediate employment

Join the military

Move out of state to seek employment/be with family/friends

Continue education

Have you been in Career Pathways before?

Yes

If yes, where and when?

If no, how did you hear about Career Pathways?

DHS.DWS Case Manager

Mail

Poster

Career Pathways Student

Friend/Family

UA-PTC Faculty/Staff

Other

If other, please list name of UA-PTC faculty/staff/student/other

What certificate/degree/etc. Will you have already completed upon entry to this program?

Career Readiness Certificate (CRS)

Employability Certificate

Bachelor’s degree

Associate’s degree

Technical Certificate

Certificate of Proficiency

Other

If other, please explain:

1 Personal Information
2 Children
3 Status/Benefits
4 Education
5 Employment
6 Submit Application

Employment

Current Employment Status:

Full-time

Part-time

Self-employed

Unemployed

Seasonal

1. Company:

Phone:

Address:

Supervisor:

Job Title:

Starting and Ending Salary:

Responsibilities/Duties:

From and To:

Reason for leaving:

May we contact your previous employer/supervisor for a reference?

Yes

2. Company:

Phone:

Address:

Supervisor:

Job Title:

Starting and Ending Salary:

Responsibilities/Duties:

From and To:

Reason for leaving:

May we contact your previous employer/supervisor for a reference?

Yes

3. Company:

Phone:

Address:

Supervisor:

Job Title:

Starting and Ending Salary:

Reason for leaving:

Responsibilities/Duties:

From and To:

Reason for leaving:

May we contact your previous employer/supervisor for a reference?

Yes

Military Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, please explain:

Professional References

1. Full Name:

Relationship:

Company/Organization:

Phone:

Address:

2. Full Name:

Relationship:

Company/Organization:

Phone:

Address:

1 Personal Information
2 Children
3 Status/Benefits
4 Education
5 Employment
6 Submit Application

*Upload Driver's License or Picture ID

This field is required

Please upload a picture (JPG or PNG images only) of your driver's license or picture ID.

Submit Application

By signing my electronic signature below, I give full permission for the Career Pathways Staff at UA - Pulaski Technical College to verify any information listed in this application, review my financial and academic record including but not limited to my FAFSA application, test scores, transcripts, and participation with the DHS/DWS Programs. I also give permission for CPI to contact the references and previous supervisors that have been provided on this application. This information will be used to determine eligibility to participants in CPI.

By signing my electronic signature below, I understand participation in CPI may be revoked at any time due to falsifying any information or engaging in inappropriate behavior. I also recognize that Career Pathways is not an entitlement program and that services are not guaranteed to applicants and/or participants.

*Signature of Applicant:

I understand that typing my full name in this box constitutes a legal signature confirming that I acknowledge and agree to the understandings above.

*Date:

You Are Here:

Career Pathways Initiative Program Application

Personal Information

Children

Status/Benefits

Education

Employment

Professional References

Submit Application