UI / DE 4365TQ

SAMPLE, this page for reference only

CALIFORNIA TRAINING BENEFITS (CTB) APPLICATION AND SCHOOL OR TRAINING QUESTIONNAIRE

SECTION A - TRAINING PROGRAM AND PROVIDER

  1. What is the name of the school or training facility you are attending?
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  2. Where is your school or training facility located? (If you attend multiple locations, provide the primary location)
    Street Address:
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    City:
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    County:
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    State:
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    ZIP Code:
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  3. What is the name, title, and phone number of the authorized representative at your school or training facility who can verify your enrollment?
    Name:
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    Title:
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    Phone:
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  4. What is the title of your training program or course of study?
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  5. What type of work will you be qualified for and seeking after you complete the school or training program?
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  6. In what cities, counties, or geographical areas in California will you seek work after you complete the program?
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  7. What are your reasons or goals for attending school or training? (Check all that apply)
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  8. What date did you first start the school or training program?
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  9. Are you required to complete an intern/externship component after your classroom training, and before your training is considered completed? (If yes, complete questions a and b)
    1. What are the expected start and end dates of the intern/externship?
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      to
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    2. Is the intern/externship paid or unpaid?
  10. On what date will you complete the entire school or training program, including completion of any intern/externships?
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  11. Is your school or training program full-time or at least 12 units or 20 hours per week including labs, homework, or other school related activities?
  12. How many units/credits or hours have you already completed?
  13. How many total units/credits/hours do you need to complete the program?
  14. What are the beginning and ending dates for the current semester, quarter, term, or session?
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    to
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  15. List all current and future start and end dates of all recess periods or breaks longer than three weeks, when you will NOT be attending school or training. (Attach academic calendars, if available)
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  16. What is your school or training program delivery method? (Check all that apply)
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  17. What degrees, valid certifications, or licenses have you earned?
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  18. What is the
    total
    estimated cost of the school or training program?
     
    $Blank line  
Name:
Form Tracking

DE 4365TQ Rev. 5 (2-20) (INTRANET)

SAMPLE, this page for reference only

CALIFORNIA TRAINING BENEFITS (CTB) APPLICATION AND SCHOOL OR TRAINING QUESTIONNAIRE

  1. If one of the following programs or sources approved, funded, or sponsored your school or training, check the appropriate box and provide the authorized program representative’s name and phone number for verification purposes.

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    Authorized Representative’s Name:
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    Phone:
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  2. If your UI benefits run out before your school or training ends, how will you successfully complete your training?
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  3. If you are a member of a labor union or trade association, is your training required, provided, or approved by your union/association? (If yes, complete the union/association information below)
    Union/Association Local Name/Number:
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    Trade/Craft:
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    Union/Association Representative’s Name:
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    Phone:
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    Are you an active journey or master-level union member in good standing with your union?
  4. Are you attending school or training for a single subject teaching credential? (If yes, indicate the credential type)
  5. Have you ever had a permanent layoff from a permanent or probationary teaching position with a public school employer? (If yes, provide the name of the employer and the layoff date below)
    Name of Public School:
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    Layoff Date:
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  6. Do you have a definite job promise after completing the school or training program? (If yes, complete the job information below)
    Start Date:
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    Employer Name:
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    Street Address:
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    Phone:
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    Job Title:
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    Rate of pay:
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    per
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    Hours per week:
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  7. Are you receiving any cash-in-hand or discretionary funds from your training provider? (This does not include grants or payments for tuition, books, supplies, or transportation)
     

    If you are receiving discretionary funds, unless you waive receipt of the funds, California law prohibits your eligibility for the CTB program. Are you willing to waive receipt of any discretionary funds? (If yes, your training provider must sign and certify your waiver on the enclosed Training Provider Questionnaire)

SECTION B - EMPLOYMENT AND AVAILABILITY FOR WORK

  1. What was the last date you worked a full-time job?
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  2. If you are currently working part-time or your last job was part-time, what are/were the start and end dates of your part-time work?
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    to
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  3. What is your usual occupation?
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  4. What other types of work are you able to perform, if any?
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Name:
Form Tracking

DE 4365TQ Rev. 5 (2-20) (INTRANET)

SAMPLE, this page for reference only

CALIFORNIA TRAINING BENEFITS (CTB) APPLICATION AND SCHOOL OR TRAINING QUESTIONNAIRE

  1. If you are not currently working, why did your last job end? (Check all that apply)

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  2. If you are currently looking for work and willing to immediately accept work, provide the following information:

    1. What types of work are you looking for? (For example: accounting, retail sales, etc.)
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    2. In what cities, counties, or geographic locations are you willing to work while attending school or training?
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    3. What days and times are you available to work while attending school or training?
      (List all start and end times for each day, for example: Monday 7 a.m. - 1 p.m., Friday 3 p.m. - 5 p.m.)
      Monday
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      Friday
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      Tuesday
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      Saturday
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      Wednesday
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      Sunday
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      Thursday
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  3. If you are willing to modify your school or training attendance in order to accept work, check all the actions you are willing to take:

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  4. If you are not currently looking for work or willing to immediately accept work, you must provide the reason(s):
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SECTION C - STUDENT CERTIFICATION

By signing below you agree to the following statements:

I understand that if I am notified that I am not eligible for the California Training Benefits program I may still be eligible to receive regular Unemployment Insurance benefits and any available extensions while attending school as long as I certify I am available for work, seeking work, and willing to drop or change school to accept an offer of work.

I understand that if I am eligible for California Training Benefits and the Training Extension, there is a maximum amount of training extension benefits that may be available regardless of the length of my training period.

I declare under penalty of perjury that the answers and information I provided on this document are true and correct and that if I submitted a Training Provider Questionnaire, it was completed by my training provider or an authorized program representative. I understand that the law provides penalties if I make false statements or withhold facts to obtain benefits.

Student Signature:
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Date Signed: 
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Provide a phone number where you can be reachedduring school or training:
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Provide an alternate phone number where you can also be reached, if necessary:
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RETURN INSTRUCTIONS:
You must complete this questionnaire and return it, along with the completed Training Provider Questionnaire (DE 4365TP), within 10 calendar days of the mailing date on the Notice of Request for School or Training Information (DE 4365T), by fax to ‎1-855-873-4359 or by mail in the enclosed envelope to the Employment Development Department, UI Center Riverside, PO Box 59910, Riverside, CA 92517-1910. To avoid processing delays, follow the Return Instructions on Page 2 of the Notice of Request for School or Training Information (DE 4365T).

Name:
Form Tracking

DE 4365TQ Rev. 5 (2-20) (INTRANET)