Apply for Google Certificate Program

Social Security Number: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Last day of most recent employment, if currently employed, use today's date. *

Wage's per hour: *

Hours per week: *

Have a current resume? Upload File or bring a printed copy to first meeting. *

Max file size: 20MB

Over the last 3 months, have you followed a personal budget, spending plan, or financial plan? *

Yes No

How confident are you in your ability to achieve a financial goal you set for yourself today? *

Not at all confident Somewhat confident Confident

Have you set aside funds that would cover your expenses for 3 months if you or someone in your family lost a job, got sick or had another emergency? *

Yes No

Do you currently have an automatic deposit or electronic transfer set up to put money away for a future use such as saving for retirement or education? *

Yes No

Over the past 3 months, would you say your household's spending on living expenses was less than its total income? *

Yes No Don't Know

In the last 3 months, have you paid a late fee on a loan or bill? *

Yes No

Select the statement that best reflects your current situation: *

No medical coverage with immediate need No medical coverage and great difficulty accessing medical care when needed Some members (e.g. children) have medical coverage All members can get medical care when needed, but may strain budget All members are covered by affordable, adequate health insurance VA medical coverage

Select the statement that best reflects your current situation: *

My immediate family or I have physical, mental, or substance use concerns that PREVENT my employment or daily life activities. My immediate family or I have physical, mental or substance use concerns that OFTEN INTERFERE with my employment or daily life activities. My immediate family or I have physical, mental or substance concerns that SOMETIMES AFFECT my employment or daily life activities. My immediate family or I have physical, mental or substance concerns that AFFECT my employment or daily life activities. My immediate family and I are healthy and participate in preventive health measures (examples include annual check-ups, screenings, vaccinations).

Select the statement that best reflects your current situation: *

No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost food. Household is on food stamps. Can meet basic food needs, but requires occasional assistance. Can meet basic food needs without assistance. Can choose to purchase the food that the household desires.

Select the statement that best reflects your current situation: *

Homeless or threatened with eviction. In transitional, temporary (short-term) or low quality housing; and/or current rent/mortgage is unaffordable (over 30% of income). In stable housing that is safe, but only barely adequate (housing may have small problems). Household is in safe, subsidized (receiving assistance to pay rent) housing with no serious problems. Household is safe, unsubsidized (no rent assistance) housing with no serious problems.

Select the statement that best reflects your current situation: *

No access to transportation (public or private) or may have car that is inoperable (can't be driven). Transportation is available, but unreliable, unpredictable, unaffordable; or may have car but no insurance, license, etc. Transportation is available and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured. Transportation is generally accessible to meet basic travel needs. Transportation is readily available and affordable; car is adequately insured.

Have you ever been convicted of a crime? *

Yes, felony Yes, misdemeanor Yes, multiple misdemeanors None

Have you been convicted of a crime in the last year? *

Yes No

Have you been incarcerated in the last year? *

Yes No

I have legal problems that may interfere with my work, education or quality of life. *

Yes No

Select the statement that best reflects your current situation: *

Needs dependent (child or elder) care, but none is available or accessible and/or dependent is not eligible. Dependent care is unreliable or unaffordable, not enough supervision is a problem for what care is available. Affordable subsidized (assistance in paying for) dependent care is available, but limited. Reliable, affordable dependent care is available, no need for subsidies (assistance in paying for care). Able to select quality dependent care of choice/No care needed.

Select the statement that best reflects your current situation: *

No clothing or seriously inadequate clothing. (For example, no coat for winter months, shoes with holes in them or soles lacking, not sufficient to assure clean clothes on a daily basis.) Unaware of where to access assistance. Very limited knowledge of resources for low-cost or free options to obtain clothing. Occasionally relies on community clothing banks. Has limited knowledge about community resources and/or financial resources to obtain clothing. Usually has the financial resource to purchase appropriate clothing. Aware of what is appropriate for work environment. Always has a financial resource to purchase appropriate clothing of choice. Aware of what is appropriate for work environment.

Which Google Certificate is most interesting to you? *

IT Support Specialist Data Analytics

I am 18 years of Age or Older *

Yes No

Race *

Caucasian or White Black or African American American Indian/Alaskan Native Asian/Native Hawaiian/Other Pacific Islander Prefer Not to Identify

Ethnicity *

Hispanic/Latino Ethnic Origin Not Hispanic/Latino Prefer Not to Identify

Number of people in your household/family? *

Veteran and Military Family Status *

Veteran/History of Military Service Member of military family (immediate family member in the military or a Veteran) Not a Veteran or member of military family

If a Veteran, what was your Military Discharge Status? *

If a Veteran, select Veteran Status Categories: *

Post 9/11 Veteran with Service-Connected Disabilities

Education Level (one choice only) *

Are you currently enrolled in any of the following? *

Have you received a certificate, or a credential issued by an industry or professional organization or certifying body? *

Yes No

How many degrees, certificates, or credentials related to the same occupation or industry do you have? *

List all degrees, certificates, or credentials issued by an industry or professional organization or certifying body. *

Do you, or someone in your household, own any of the following? Select all that apply. *

Desktop computer or laptop Smartphone Tablet or other wireless computer Another type of computer

Do you have access to the Internet in your current living space? *

Yes, a cellular data plan for a smartphone or other mobile device Yes, Broadband (high speed) Internet service such as cable, fiber optic, or DSL service installed Yes, Satellite Internet service installed Yes, Dial-up Internet service installed Yes, Other service – please specify:

No access to the Internet in my current living space

If the above is checked: how many miles to your nearest public access to the Internet? *

I will be able to achieve most of the goals I have set for myself. *

When facing difficult tasks, I am certain that I will accomplish them. *

In general, I think I can obtain outcomes that are important to me. *

I believe I can succeed at most any endeavor (anything) I set my mind to. *

I will be able to successfully overcome many challenges. *

I am confident that I can perform effectively (do well) on many different tasks. *

Compared to other people, I can do most tasks very well. *

New ideas and projects sometimes distract me from previous ones. *

Delays and obstacles (things that get in the way) don’t discourage me. *

I have been obsessed with (constantly thinking about) a certain idea or project for a short time but later lost interest. *

I often set a goal but later choose to follow a different one. *

I have difficulty keeping my focus on projects that take more than a few months to complete. *

Application for Google Certificate Program