Fill - Free fillable Career Technology Program Application (The Chickasaw Nation) PDF form

Page 1 of 4

Form no. 04572 CS-EDU Rev. 6/2020

Career Technology Program Application

Name:

First Middle Last Suffix

Mailing address:

Street City State County ZIP

 Same as mailing

Physical address:

Phone no.: ( ) Email address:

NOTE: All Chickasaw Nation correspondence will be sent to this email address. This will ensure a more efficient notification

process regarding the status of your application. Students are responsible for checking their email regularly to guarantee

receipt of correspondence.  I do not have an email address. Please continue to issue all correspondence via U.S.

mail.

Birth date: Age: Gender:  Male  Female

Have you served in the military?  Yes  No

What branch and years served?

The Chickasaw Nation Career Technology Program (CTP) is available to part-time and full-time Chickasaw students

attending a state or nationally accredited career technology center, trade school or private licensed training facility, whereby

graduating students receive a professional certification or license upon completion of their program. Eligibility is not income-

based and students are not required to live within the boundaries of the Chickasaw Nation to qualify. The student must be

18 years of age (minors under the age of 18 will be considered on a case-by-case basis) and possess a Chickasaw Nation

citizenship card. This program provides funding for professional certifications only. Students enrolled in degree-seeking

courses must apply through the higher education program. The following is a list of grants that you may be considered

eligible to receive.





GRANTS

Please read the description of each and check the box for which you wish to be considered.

 Career Technology Program (CTP) Grant

Part-time and full-time Chickasaw students attending a state or nationally accredited career technology center, trade

school or private licensed training facility are eligible. The amount of the CTP grant shall be based on the student’s

programs tuition and fee costs with $6000 being the maximum award amount per certification.

An invoice or billing statement must be submitted to process any award amount. The student’s federal and/or state

financial aid award will be taken into consideration when processing the CTP grant award amount. All students must

submit a high school transcript, high school equivalency or college transcript; eligibility is not dependent on completion

or grade point average. Application must be made before the student’s course completion date to be eligible.

 Exam and Licensure Assistance Grant

Provides assistance for licensing and certification exams or licensure fees. Students may be eligible for up to

$500 per exam or licensure fee. Awards may be dispersed as reimbursement or on a prepayment basis (if applicable

to payee). Application must be made within six months of the student's receipt of payment.

1. Prepayment: 2. Reimbursement

a. Application a. Application

b. Copy of exam b. Receipt of payment

registration or c. Copy of professional

licensure certification or licensure

Education Services

300 Rosedale Road / Ada, OK 74820 / Phone (580) 421-7711

Website: http://www.chickasaw.net/Services/Career-Technology-Program.aspx

Bill Anoatubby

Governor

Page 2 of 4

Form no. 04572 CS-EDU Rev. 6/2020

 Text Book and Supplies Assistance Grant

Provides assistance for required text books and supplies as determined by the student's program. The text book and

supplies assistance grant is available once per certification. Part-time and high school students may qualify for $250.

Full-time students may qualify for $500. Awards may be disbursed as reimbursement or on a prepayment basis (if

applicable to payee). Application must be submitted prior to the course completion date.

1. Prepayment: 2. Reimbursement

a. Application a. Application

b. Copy of itemized b. Receipt of payment

invoice of detailed

billing statement

Page 3 of 4

Form no. 04572 CS-EDU Rev. 6/2020

Bill Anoatubby

Governor

Career Technology Program Application

Student name:

Name of training facility:

Mailing address:

Street City State ZIP

Phone no: ( ) Fax no: ( )

Facility contact person:

Email address: Direct phone no: ( )

License/Certification:

Start date: Completion date:

Total number of training/clock hours to be completed:

Please check the appropriate box for your coursework:

 On-site  Online

Please check the appropriate box for your program’s billing schedule:

 First quarter  Second quarter  Third quarter  Fourth quarter

 Spring  Fall  Total Program

Student Contract – By signing below, I declare that I have read and understand the Chickasaw Nation Career

Technology Student Handbook as it is related to funding students who are attending professional certification programs.

The student handbook can be found at:

http://www.chickasaw.net/Services/Career-Technology-Program.aspx.

NOTICE: Funding will not be provided for an incomplete application.

All documentation listed below must be received in the career technology office prior to course completion date:

 Career technology program application

 Invoice or billing statement from the training facility which itemizes all program costs

 High school transcript, high school equivalency or college transcript

Student signature Date

Parent/legal guardian signature (if applicable) Date

Education Services

Career Technology Program

Page 4 of 4

Form no. 04572 CS-EDU Rev. 6/2020

Student Authorization for Disclosure of Information

In Education Records

Pursuant to Family Educational Rights and Privacy Act of 1974, as amended

Instructions:

To authorize the Chickasaw Nation Career Technology Program to obtain your educational information and to authorize

the Chickasaw Nation Career Technology Program to release your educational information to individuals or the

college/university you are attending

1. Fill out all appropriate fields on this form; and

2. Hand-deliver or mail the form to the address to the right.

3. Note: Forms will not be accepted without a signature.

First name:

Middle name:

Last name:

Suffix:

Birth date:

Please enter the name of the organization(s) or individual(s) to whom the authorization is given or revoked. You may

enter more than one name. Enter only ONE name per space.

Organization(s) authorized

 given  revoked

Individual(s) authorized

Birth date

 given  revoked

Authorization:

I hereby authorize the to disclose my educational record(s) to the above-mentioned

organization(s) or individual(s)

and also authorize to disclose or obtain my educational record(s) to/from

Student’s signature Date

Parent/legal guardian signature (if applicable) Date

Education Services

Career Technology Program

Bill Anoatubby

Governor

RETURN COMPLETED FORM TO:

The Chickasaw Nation

Education Services

Career Technology Program

300 Rosedale Rd

Ada, Oklahoma 74820

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