Form EMS10065 "Student Eligibility Questionnaire/Commissioner Approved Training Application" - Washington

What Is Form EMS10065?

This is a legal form that was released by the Washington State Employment Security Department - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2013;
  • The latest edition provided by the Washington State Employment Security Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form EMS10065 by clicking the link below or browse more documents and templates provided by the Washington State Employment Security Department.

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Download Form EMS10065 "Student Eligibility Questionnaire/Commissioner Approved Training Application" - Washington

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Student Eligibility
Questionnaire/Commissioner Approved
Training Application
Name
Social Security or Identification number
Telephone number
(
)
Claimant’s name and address:
Return this form by mail or fax to:
Employment Security Department
Unemployment Insurance Imaging
P.O. Box 19019
Olympia, WA 98507-0019
Fax: 1-800-301-1796
Note: You may be eligible to receive benefits while you train to set up your own business. To apply, do not use this
application. Fill out the application for the Self-Employment Assistance Program (SEAP). For information or to download
the application go online at
www.esd.wa.gov/training-programs
or contact your nearest WorkSource employment center.
Student eligibility questionnaire
You must be immediately able and available for work and actively seeking full-time work to qualify for benefits. Your enrollment or
attendance in school raises a question about your eligibility for benefits. In some cases, we can approve you for Commissioner
Approved Training (CAT), which waives the job-search requirements. See the optional CAT application at the end of this
questionnaire.
If you are completing a separate Training Benefits application, you do not need to complete this questionnaire.
Please answer the following questions about your school attendance. Return this form and any other documents that may help us
make a decision about your claim to the address listed.
1.
School name: __________________________________________________________________________________________
School address: _________________________________________________________________________________________
School counselor or contact name: __________________________________________________________________________
Counselor or contact phone number: ________________________________________________________________________
2.
Please list the name of your training program or major as listed in your training provider’s course catalogue. You can find this
information at www.careerbridge.wa.gov: ____________________________________________________________________
3.
I am a freshman ______ sophomore ______ junior ______ senior ______ other ______________________________________
4.
What certificate or degree are you pursuing? __________________________________________________________________
5.
When did you originally begin or when will you begin this training program? ________________________________________
6.
When did you register for this quarter or term? ________________________________________________________________
7.
Classes began this quarter or term on: _______________________________________________________________________
Classes will end this quarter or term on: ______________________________________________________________________
8.
When will you complete or graduate from the training program? __________________________________________________
9.
Does the school or training program consider this training full-time or part-time? F/T ___ P/T ___
10. How do you attend (check all that apply)? online _____ in-person _____ correspondence _____
other, please explain: ____________________________________________________________________________________
11. Are you required to attend on specific days and at certain times? Yes ___ No ___
Page 1
EMS 10065 (Rev. 4/13)
Student Eligibility
Questionnaire/Commissioner Approved
Training Application
Name
Social Security or Identification number
Telephone number
(
)
Claimant’s name and address:
Return this form by mail or fax to:
Employment Security Department
Unemployment Insurance Imaging
P.O. Box 19019
Olympia, WA 98507-0019
Fax: 1-800-301-1796
Note: You may be eligible to receive benefits while you train to set up your own business. To apply, do not use this
application. Fill out the application for the Self-Employment Assistance Program (SEAP). For information or to download
the application go online at
www.esd.wa.gov/training-programs
or contact your nearest WorkSource employment center.
Student eligibility questionnaire
You must be immediately able and available for work and actively seeking full-time work to qualify for benefits. Your enrollment or
attendance in school raises a question about your eligibility for benefits. In some cases, we can approve you for Commissioner
Approved Training (CAT), which waives the job-search requirements. See the optional CAT application at the end of this
questionnaire.
If you are completing a separate Training Benefits application, you do not need to complete this questionnaire.
Please answer the following questions about your school attendance. Return this form and any other documents that may help us
make a decision about your claim to the address listed.
1.
School name: __________________________________________________________________________________________
School address: _________________________________________________________________________________________
School counselor or contact name: __________________________________________________________________________
Counselor or contact phone number: ________________________________________________________________________
2.
Please list the name of your training program or major as listed in your training provider’s course catalogue. You can find this
information at www.careerbridge.wa.gov: ____________________________________________________________________
3.
I am a freshman ______ sophomore ______ junior ______ senior ______ other ______________________________________
4.
What certificate or degree are you pursuing? __________________________________________________________________
5.
When did you originally begin or when will you begin this training program? ________________________________________
6.
When did you register for this quarter or term? ________________________________________________________________
7.
Classes began this quarter or term on: _______________________________________________________________________
Classes will end this quarter or term on: ______________________________________________________________________
8.
When will you complete or graduate from the training program? __________________________________________________
9.
Does the school or training program consider this training full-time or part-time? F/T ___ P/T ___
10. How do you attend (check all that apply)? online _____ in-person _____ correspondence _____
other, please explain: ____________________________________________________________________________________
11. Are you required to attend on specific days and at certain times? Yes ___ No ___
Page 1
EMS 10065 (Rev. 4/13)
Name
Social Security or Identification number
12. What is your class schedule this quarter or term?
Class name
Course number
Credit hours
Class times
Class days
13. How many hours do you spend or will you spend in class, class preparation and study each day? _________________________
14. How do you or will you pay for your school or training program? Check all that apply and list amounts:
___ Grant: $__________
___ Gift: $__________
___ Scholarship: $__________
___ Personal loan: $__________
___ Student loan: $__________
___ Out of pocket: $__________
___ Other: _______________________________________________________________________________
15. Would you have to return any of the money if you were to drop any of your classes? ___ Yes ___ No
16. List the occupation you have the most experience in: ___________________________________________________________
How many years? _______________________________________________________________________________________
List any other significant occupations and years of experience:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
17. In the past, have you worked full-time while attending school? Yes ___ No ___. If yes, how were you able to manage it?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
18. List your last three jobs beginning with the most recent:
Business name
Occupation
Start date
End date
19. Did you look for work or participate in any job-search activities through your WorkSource employment center during the last
week you claimed? Yes __ No __
If yes, list contacts made:
Date
Employer name /Activity
Employer / WorkSource address
Position
If no, explain why: ______________________________________________________________________________________
20. What will you tell employers about your availability for work when you apply for or are offered a job? ____________________
______________________________________________________________________________________________________
21. What days each week can you work (check all that apply)? ___ Su ___ M ___ Tu ___ W ___ Th ___ F ___ Sa
22. What shifts are you available to work (check all that apply)? days ____ swing ____ graveyard ____
Page 2
EMS 10065 (Rev. 4/13)
Name
Social Security or Identification number
23. How many hours per day and days per week can you work? _______ hours per day; _______ days per week
24. If you were offered work that conflicts with your class schedule, would you drop the classes to accept the job? Yes ___ No ___.
Please explain your answer: _______________________________________________________________________________
______________________________________________________________________________________________________
25. Are your classes available other hours and will the school let you change at this stage of the school term? Yes ___ No ___.
26. Are you willing to forfeit your tuition if the school will not give you a refund? Yes ___ No ___.
We need you to provide this information so we can make a decision on your unemployment claim. If we need additional information,
we will contact you.
You have the right to an interview by telephone or in-person before we make a decision. If you want an interview, contact the claims
center. You may have any person; including an attorney assist you at the interview. You may present evidence, documents or
witnesses; cross-examine witnesses or parties present; and ask for copies of all records or documents on the issue.
I have read and understand my rights. I made this statement to get unemployment benefits. The information I provided is true to the
best of my knowledge.
Your signature ___________________________________________________ Date _______________________________________
Your telephone number: (________) ___________________ Email address (optional) ____________________________________
IMPORTANT NOTE:
This information will be used to determine if you are eligible for benefits.
Return this completed form to the address listed. If you do not, we may deny your benefits and you may have an overpayment.
Page 3
EMS 10065 (Rev. 4/13)
Name
Social Security or Identification number
Commissioner Approved Training (CAT) Application
Only complete this section if you want to apply for CAT.
CAT allows you to attend full-time training and receive unemployment benefits without looking for work. You must continue to seek
work unless we tell you that we have approved you for CAT.
You may qualify for CAT if your training is full-time and:
There are limited jobs in your main occupation and training gives you a better chance of finding work because the skills you
gain will make you more employable in an occupation with openings;
Training is required by your job; or
You are physically unable to continue working in your current job.
CAT does not increase the benefit amount on your claim or extend the number of weeks you receive benefits. Depending on the length
of your training, benefits may run out before you complete your training. You are responsible for your own financial planning that
may include paying for training after your benefits run out.
1.
Do you have any degrees or certificates? Yes ___ No ___. If yes, what are they and what year did you receive them?
______________________________________________________________________________________________________
2.
List specific jobs you will be qualified to do after you complete training:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
3.
If these jobs are not available where you live, will you move to another area to accept work? Yes ___ No ___
If yes, what areas? _______________________________________________________________________________________
4.
How will you pay for school and school-related expenses if your unemployment benefits run out before training ends?
______________________________________________________________________________________________________
5.
Is this training funded or sponsored under a special grant or program, such as Workforce Investment Act (WIA), Trade Act or
Worker Retraining? Yes __ No __ If yes, please attach proof of approval and provide the following:
Counselor's name: _______________________________________________________________________________________
Phone number: _________________________________________________________________________________________
Location: ______________________________________________________________________________________________
Name of special grant and program: _________________________________________________________________________
6.
Does your union or employer require this training? Yes __ No ___. If yes, provide union or employer name and phone number.
______________________________________________________________________________________________________
7.
Did you receive a Worker Adjustment and Retraining Notice (WARN)? Yes __ No __. If yes, when and from which employer?
______________________________________________________________________________________________________
8.
Have employers said you need updated skills or certification to continue working in your main occupation? Yes __ No __.
If yes, please explain: ____________________________________________________________________________________
9.
Do you have any injuries, illnesses, or other conditions that prevent you from returning to your main occupation? If you have
medical documentation to support this, please attach a copy (not required). Yes __ No __. If yes, please explain:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
I am applying for CAT. I understand this information may be verified and will be used to decide if I am eligible. I understand that I must
immediately report any changes to my schooling to the unemployment claims center. I authorize the school, training facility and my
counselor to release information to the Employment Security Department about my enrollment, participation in training, attendance and
progress in the training. I understand that I must continue to seek and record my work search unless I am notified that CAT has been
approved.
Signature ___________________________________________________ Date ______________________
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EMS 10065 (Rev. 4/13)
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