Pensacola State College does not discriminate on the basis of race, color, national origin, sex, disability, age, ethnicity, religion, marital
status, pregnancy, sexual orientation, gender identity or genetic information in its programs, activities and employment. For inquiries
regarding the College’s non- discrimination policies, contact the Executive Director of Institutional Equity and Student Conduct, 1000
College Boulevard, Building 5, Pensacola, Florida 32504, (850) 484-1759
Revised 1/30/2020
Employment Status: Select one.
Unemployed – Not Seeking Employment
Unemployed – Looking and Eligible for Employment
Employed (Paid or Unpaid or Absent Because of Illness, etc.)
Employed with Notice of Termination or in Transistion out of Military
If Unemployed: Answer Yes or No.
Have you been unemployed for 27 or more weeks at the time of program entry? Yes No
Income Status: Answer Yes or No to each question.
1. Do you or a member of your immediate family receive benefits through SNAP/TANF, SSI, or other state public assistance? Yes No
2. Does your total family income exceed the higher of the poverty line or 70% of the lower living standard income level? Yes No
3. Are you currently in a foster program? Yes No
4. Do you have a disability and a personal income that is at or below the poverty line? Yes No
5. Are you a youth living in a high-poverty area? Yes No
Income Status: Answer Yes, No, or Not Applicable.
Will you exhaust TANF eligibility within 2 years of program entry? Yes No Not Applicable
Background: Select all that apply.
On public assistance
Living in rural area
Single parent
Single pregnant woman
Perceived employment barriers
Previously or currently subject to any stage of the criminal justice process
Low-income individual (or their dependent) employed primarily in farming, currently unemployed, or finding difficulty obtaining work for
12 months out of the last two years
Migrant or seasonal farmworker (or their dependent)
Homeless but staying in non-traditional housing (ex: park, abandoned building, or bus station)
Homeless without a fixed, regular nighttime residence
Child of migrants who have changed school districts in the last 3 years due to parents’ seasonal employment
Runaway
Previously worked as an adult without pay to care for home and family and is unemployed or underemployed
Previously dependent on public assistance or income of a relative and now unemployed or underemployed
Parent whose youngest child will become ineligible (at age 16) to receive assistance under the program for Aid to Families
with Dependent children under Part A of the Title IV of the Social Security Act
Unemployed dependent spouse of a member of the Armed Forces on active duty and whose family income is significantly
reduced because of deployment, a permanent change of station, or the service-connected death or disability of the spouse
Goal(s) for Attending Class(es): Select all that apply.
Pass the GED
Enter post-secondary education or job training
Retain current job (unsubsidized)
Obtain a job (unsubsidized)
I affirm that the information provided in this application is true and accurate. I understand that enrollment information and test scores
may be released for federal and state reporting requirements. I have been provided the Social Security Collection and Usage Statement.
Signature _________________________________________ Date __________________
