ISY SELF-CERTIFICATION FORM

Identifying Information
Applicant’s Last Name*
Applicant’s First Name*
Applicant’s MI*
Address*
County of Residence*
City*
State*
Zip Code*
Participant ID*
Application Date*
Certification
I hereby certify under penalty of law, that the following information is true. I verify that I meet the below eligibility criteria: (Type in the box below or use the checkbox to select the accurate statement.)*
In-School Youth who requires additional assistance to complete an educational program or to secure and hold employment as defined by the local board:
- Youth is at risk of dropping out of school (as certified by school counselor)
- Youth is part of a family who has received medical assistance, LIHEAP assistance or public housing/rent subsidy within the past 6 months
- Disabled youth who needs to complete an educational program or secure and hold employment
Youth who lacks significant work history, as defined by one of the following:
- Has no unsubsidized work history
- Has been unemployed for more than 15 weeks of the last 6 months
- Lacks meaningful work experience and/or general job search, basic entry level or employment readiness skills
- Other Barrier:
I attest that the information stated above is true and accurate, and understand that the above information, if misrepresented, or incomplete, may be grounds for immediate termination and/or penalties as specified by law.
Applicant’s Signature*
Date*
MM slash DD slash YYYY
Applicant’s phone number*
Signature of parent or guardian*
Date*
MM slash DD slash YYYY

Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program.