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G E T G U A M
T E L E W O R K I N G
GET
GUAM
TE
LEWORKIN
G
LO
ANPROGRA
M
Providing
e
mployment
op
portunitiesto
Ind
ividualswith
d
isabilities!
ThisdocumentwasdevelopedbytheGet
Guam
TeleworkingLoanProgram.Fundingisprovidedbythe
RehabilitationServicesAdministration.
GrantNo.CFDA84.235T
MapToGSAT
Get Guam Teleworking Loan Program
University of Guam Guam CEDDERS
Office o f Academic Affairs & Student Affairs
House # 19 Dea ns Circ le
UOG Sta tion
Mangilao, GU 96923
p
contactorvisit:
Please return this portion to:
GetGuamTeleworkingLoan
Program
UniversityofGuamGuamCEDDERS
OfficeofAcademic&Stude
ntAffairs
House#19DeansCircle
UOGStation
Mangilao,GU96923
Phone:735-2490/1
TTY:735-2491
Fax:734-8378
Email:[email protected]
Th
U
i
i
fG
i
l
i
l
d
id
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8/3/2019 Telework Application.pdf
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GGTisafederally
fundedprogram,
administeredbythe
GuamCenterfor
Excellence
in
Developmental
DisabilitiesEducatio
n,Research,and
Service(CEDDERS).
Ourmissionisto
provide
a
program
thatoffersaffordable
financialloanstohelp
individuals
with
disabilities
purcha
se
equipmentinorder
to
Telework.
GetGuam
Teleworking(GGT)
Lo
anProgram
E
quipmentmay
include,b
utisnot
limitedto:
Computers,printersan
drelated
peripherals
Software
Faxmachines
Scanners
Office
machines
(e.g.,
calculators)
Telecommunicationdevices
Home
modifications
for
accessibility
and/ortocreate
homeoffices
EligibilityRequiremen
ts
Tobe
eligible
for
a
GGTLoan,
applicantsmust:
BeaGuamResident
Beatleast18yearsold
Beapersonwithadisa
bility
ConfirmTelework
intent
Employmentwith
an
existing
businessorSelf-Employ
ment
Receiving
an
application
iseasy,
contacttheGGTstaffat:
735-2490/1
735-2491
(TTY)
Email:[email protected]
WhatifIneedhelpcomple
tingthe
application?
Ifyou
have
questions
orneed
assistancecompletingtheap
plication,
GGThasahelpfulstaffthat
wouldbe
happytoassistyou.
Please print or type:
Name: _____________________________________________________
Address: ___________________________________________________City: ____________________State: _____________________________Zip: __________ E-mail: ____________________________________Phone: _______________ Fax: ________________________________Date ofBirth: ______________________________________________Are you a Guam Resident? Yes _____ No _____Describe your disability: ________________________________________________________________________________________________
WhatisTelework?
Telework
is
de
fined
as
paid
employment,
thatis
regularly
performedataplaceotherthanthe
employers
office
or
place
of
business,suchasa
workershomeor
aTeleworkcenter.
Theemployment
maybeeitherfull-tim
eorpart-time.
Paidself-employmentregardlessof
businesslocationisa
lsoconsidered
Telework.
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8/3/2019 Telework Application.pdf
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Get Guam Teleworking Loan Program University of Guam, Office of Academic AffairsHouse 19 Deans Circle UOG Station Mangilao, Guam 96923 (671) 735-2490 (671) 735-2491 (TTY) (671) 734-8379 (Fax)
GGT Intent Agreement.doc Revised on: 07/25/2005 Page 1 of 1
Applicant Name: Telework Type: New Business
Working with
Doing Business As: Existing Business
Contact Information
Address: Phone:
Fax:
Email:
If a new business, please attach all supporting documents and an approved business plan.
If working with an existing business, please attach all supporting documents of a Telework agreement
from employer.
Applicant Signature Date (MM/DD/YY)
Telework Job Description:
Get Guam TeleworkingIntent Agreement
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8/3/2019 Telework Application.pdf
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GetGuamTeleworkingLoanProgramUniversityofGuam
,OfficeofAcademicAffairs
House19DeansCircleUOGStatio
nMangilao,Guam96923(671)735-249
0(671)735-2491(TTY)(671)734-8379
(Fax)
TheUniversityofGuam
isanequalopportunityemployerandprovider
ClosedEndUnsecuredSecured
_______________________
_____Branch/Office
IMPORTANT:ReadtheseDirectionsbeforecompletingthisApplication
Ifthisisanapplicationforanindividualandyouarerelyingonyourownincomeofassetsandnottheincome
orassetsofanotherpersonasthebasisforrepayme
ntofthecreditrequested,completeonlySectionsAand
D,andsignthisapplication.Iftherequestedloanistobesecured,pleasealsoco
mpleteSectionsCandE.
Ifthisisanapplicationforajointloaninvolvingyouandanotherperson,complete
allSectionsexceptE,and
bothpartiesshouldsign
thisapplication.Iftherequestedloanistobesecured,th
encompleteSectionE.
Checkthe
AppropriateBox
Ifthisisanapplicationforanindividualloan,butyou
arerelyingonincomefromalimony,childsupportor
separatemaintenanceo
rontheincomeorassetsofanotherpersonasthebasisforrepaymentofthecredit
requested,completeall
SectionsexceptEtotheexte
ntpossible,andsignthisapplication.Iftherequested
loanistobesecured,pleasecompleteSectionE.
AmountReques
ted
Re-Pa
ymentTermRequested
ProceedsofLoantobeUsedfor
12Months
24Months
36Months
$
48Months
60Months
GetGuamTeleworking
Lo
anApplicationforCredit
PacificIsland
Micro
creditInstitute
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8/3/2019 Telework Application.pdf
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GetGuamTeleworkingLoanProgramUniversityofGuam
,OfficeofAcademicAffairs
House19DeansCircleUOGStatio
nMangilao,Guam96923(671)735-249
0(671)735-2491(TTY)(671)734-8379
(Fax)
A:InformationaboutApplicant
B:Inform
ationaboutCoApplican
t/OtherParty
FullName(Last,F
irst,Middle)
DateofBirth
(MM/DD/YYYY)
FullNam
e(Last,First,Middle)
DateofBirth
(MM/DD/YYYY)
SocialSecurityNumber
DriversLicen
seNo.
SocialSecurityNumber
DriversLicenseNo.
CurrentHomeStre
etAddress
YearsThere
CurrentHomeStreetAddress
YearsThere
CityorVillage
State
Zip
HomePhone
CityorV
illage
State
Zip
HomePhone
CurrentMailingAddress
CurrentMailingAddress
CurrentEmployer
YearsThere
CurrentEmployer
YearsThere
PositionorTitle
NameofSupervisor
WorkPhone
Position
orTitle
NameofSup
ervisor
WorkPhone
PreviousEmployer
YearsThere
Previous
Employer
YearsThere
PreviousEmployersAddress
Previous
EmployersAddress
CurrentSalaryorC
ommission
No.of
dependents
Ages
CurrentSalaryorCommission
No.of
de
pendents
Ages
$
per
$
per
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8/3/2019 Telework Application.pdf
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GetGuamTeleworkingLoanProgramUniversityofGuam
,OfficeofAcademicAffairs
House19DeansCircleUOGStatio
nMangilao,Guam96923(671)735-249
0(671)735-2491(TTY)(671)734-8379
(Fax)
OtherIncome(Alimony,childsupport,orseparate
maintenanceneednot
berevealedifyoudonotwishit
consideredasabasisforrepayment)
SourceofOther
Income
OtherIncome(Alimony,childsupport,orseparate
maintenanceneednotberevealedifyoudon
otwishit
considered
asabasisforrepayment)
SourceofOther
Income
$
per
$
per
Alimony,ChildSup
portSeparateMaintenancereceivedunder
Alimony,ChildSupportSeparateMaintenancereceivedunder
CourtOrder
WrittenAgreement
Verbal
Understanding
CourtOrder
WrittenAgreem
ent
Verbal
Understanding
Haveyoueverborrowedfrom
us?
When
Branch
Haveyoueverborrowedfrom
us?
When
Branch
Yes
No
Yes
No
CheckingAccount
No.
NameofFinancialInstitution
CheckingAccountNo.
Na
meofFinancialInstitution
SavingsAccountN
umber
NameofFinancialInstitution
Savings
AccountNumber
Na
meofFinancialInstitution
NameofNearestR
elativeNotLivingWith
You
Relationship
Nameof
NearestRelativeNotLivingWith
You
Relationship
Address
PhoneNumber
Address
PhoneNumber
C:ApplicantsMartialStatus(DoNotCompleteifthisisanapplicationforanunsecuredloan)
Married
Separated
Unmarried(includesSingle,
DivorcedorWidowed)
CoApplicant/OtherParty
Married
Separated
Unmarried(includesSingle,
DivorcedorWidowed)
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8/3/2019 Telework Application.pdf
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GetGuamTeleworkingLoanProgramUniversityofGuam
,OfficeofAcademicAffairs
House19DeansCircleUOGStatio
nMangilao,Guam96923(671)735-249
0(671)735-2491(TTY)(671)734-8379
(Fax)
D:AssetandDebtInformation
(IfSectionBhasbeencompleted,thisSectionshouldbecompletedgivinginformationaboutboththeApplicantandCoApplicant/OtherParty.Pleasemark
Applicantrelatedinfo
rmationwithanA.IfSectionBw
asnotcomplete,onlygiveinformationabouttheApplicantinthisSec
tion.)
*AssetsOwned(Useseparateformifnecessa
ry)
D
escriptionofAssets
Value
E
ncumbered?
Name(s)ofOwner(s)ofRecord
Cash
$
Automobiles(Year,Make&Model)
$
D
escriptionofAssets
Value
Encumbered?
Name
(s)ofOwner(s)ofRecord
CashValueofLife
Insurance(Issuer,FaceValu
e)
$
RealEstate(Location&DateAcquired)
$
MarketableSecurities(Issuer,Type,Shares)
$
Other(List)
$
TOTAL
ASSETS
$
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8/3/2019 Telework Application.pdf
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GetGuamTeleworkingLoanProgramUniversityofGuam
,OfficeofAcademicAffairs
House19DeansCircleUOGStatio
nMangilao,Guam96923(671)735-249
0(671)735-2491(TTY)(671)734-8379
(Fax)
*OutstandingDeb
ts(Includechargeaccount,
installmentcontracts,creditc
ards,rentmortgage,etc.Includeatleast3credit
references.Useseparatesheetsifnecessary.)
Nameof
Creditor
Typeo
fDebtor
Acco
untNo.
NameinWhich
AccountCarrie
d
Original
Debt
Present
Balance
Monthly
Payments
Amount
PastDue
1.LandlordorMortgageHolder
RentPayment
Mortgage
$
$
$
$
2.
$
$
$
$
3.
$
$
$
$
4.
$
$
$
$
5.
$
$
$
$
TOTA
LDEBTS
$
$
$
$
IfYes,forwhom
?(givename)
ToWhom?(givename)
AreyouacoMaker,endorseror
guarantoronanyloanorcontract?
Yes
No
IfYes,giv
eamount
IfYes,towhomowed?(givename)
Arethereanyunsa
tisfiedjudgments
againstyou?
Yes
No
$
IfYes,Where?(givelocation/city/state
/country)
YearFiled
Haveyoubeendeclaredbankruptinthelast14
years?
Yes
No
Otheroblig
ations(e.g.liabilitytopayalimony,childsupport,separate
maintenanceUseseparatesheetifnecessary)
E:SecuredCredit
(brieflydescribethepropertytobegivenassecurity)
Andlistnamesand
addressesofallcoownersofproperty
Ifthesecurityisto
berealestate,give
thefullnameofyourspouse(ifany)
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8/3/2019 Telework Application.pdf
10/14
GetGuamTeleworkingLoanProgramUniversityofGuam
,OfficeofAcademicAffairs
House19DeansCircleUOGStatio
nMangilao,Guam96923(671)735-249
0(671)735-2491(TTY)(671)734-8379
(Fax)
I/WEauthorizeBankofGuamtomakew
hatevercreditinquiriesthatitdeemsnecessaryinconnec
tionwiththiscredit
applicationorinthe
courseofrevieworcollectionofanycreditextendedinrelianceonthisapplication.I/
WEauthorizeandinstruct
anypersonorconsumerreportingagencytocom
pileandfurnishBankofGua
manyinformationthatitmayhaveorobtaininresponse
tosuchcreditinquiriesandagreethatsuchinformation,alongwiththisapplicationshallremainBankofGu
amspropertywhetheror
notcreditisextende
d.
Allinformatio
nsetforthinthisapplicationisdeclaredtobeatruerepre
sentationofthefacts,madeforthepurposeofabtaining
thecreditrequested
,andanywillfulmisrepresentationonthisapplicationcouldresultincriminalaction.
ApplicantsSignature
Date
(M
M/DD/YYYY)
C
oApplicantsSignature
Date
(MM/DD/YYYY)
MONTHLYBUDGE
T(completeallcases)
NetIncome
$
Alimony&ChildSupport
$
TotalMo.Payments
$
Life&HealthIns.Premium
$
PaymentonthisLo
an
$
Miscellaneous
$
Food
$
Medical
$
TOTALEXPENSES
$
CarMaint./Insurance
$
Clothing
$
NETEXCESSINCOME
$
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8/3/2019 Telework Application.pdf
11/14
Get Guam Teleworking Loan Program University of Guam, Office of Academic AffairsHouse 19 Deans Circle UOG Station Mangilao, Guam 96923 (671) 735-2490 (671) 735-2491 (TTY) (671) 734-8379 (Fax)
GGT Equipment List.doc Revised on: 07/25/2005 Page 1 of 1
Get Guam TeleworkingEquipment List
Equipment Make & Model (Brand) Company Cost
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
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8/3/2019 Telework Application.pdf
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Get Guam Teleworking Loan Program University of Guam, Office of Academic AffairsHouse 19 Deans Circle UOG Station Mangilao, Guam 96923 (671) 735-2490 (671) 735-2491 (TTY) (671) 734-8379 (Fax)
GGT Alternative Funding Sources Worksheet.doc Revised on: 07/25/2005 Page 1 of 3
Explanation: Funding for Assistive technology devices may be available through sources such asstate agencies, insurance companies, school districts or other private organizations. The purpose ofthis worksheet is to gather information that may help the consumer determine if there areother funding options available. The existence of alternative funding may, in some instances,eliminate the need for the consumer to take out a loan, or may reduce the amount of money to beborrowed. GGT supports informed consumer choice and does not want to encourage unnecessaryconsumer debt.
COMPLETION OF THIS FORM IS OPTIONAL. The information provided will NOT be used toapprove or deny a GGT Assistive technology loan, and GGT will NOT require a consumer touse another available funding source in place of a GGT loan. Please be aware that GGTcannot assure eligibility for, or authorization of funding by another agency. It is theconsumers choice and responsibility to pursue funding from any source suggested by GGTor its representatives.
Instructions: Please answer the following questions.
1. Person needing assistive technology Phone
2. Contact person Phone
(if other than person with disability)
3. Date of birth (MM/DD/YY) 4. Diagnosis
5. At what age did the disability occur?
0 3 years 4 21 years 21 65 years 65 + years
6. Functional Disabilities: (check all that apply)
Communication Recreation
Hearing Self care
Learning Vision
Mobility Work / Employment
Other
Get Guam TeleworkingAlternative Funding Sources Worksheet
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8/3/2019 Telework Application.pdf
13/14
Get Guam Teleworking Loan Program University of Guam, Office of Academic AffairsHouse 19 Deans Circle UOG Station Mangilao, Guam 96923 (671) 735-2490 (671) 735-2491 (TTY) (671) 734-8379 (Fax)
GGT Alternative Funding Sources Worksheet.doc Revised on: 07/25/2005 Page 2 of 3
7. Place of Residence: (check all that apply)
Single Family Home Apartment Own
Assisted Living Facility Group Home Rent HUD / Section 8
Nursing Home Other
8. What major life activities will the assistive technology be used for? (check all that apply)Employment / Work School / Education Communication Mobility
Home / Independent Living Community / Activities Other
9. Have you ever or are you currently receiving services from the following agencies: (check all thatapply)
Agency Present Past DeniedOfficeUse
Guam Early Intervention Program (GEIP)
Guam Centers for Independent Living (specify)
Department of Behavioral Health Services
Department of Health Services (DHS)
Foster Care System
Foundation / Service Organizations (specify)
Indian Health Services (IHS)
Independent Living and Rehabilitation Services (ILRS-RSA)
Independent Living Centers (ILCs)Medicare
Private Insurance Co. (specify)
Private Trust
Temporary Aid to Needy Families (TANF)
Telecommunications Equipment Distribution Program
School District (specify)
Secure CareSocial Security Administration (SSA)
Veterans Administration (VA)
Veterans Rehabilitation (VR / RSA)
Workers Compensation
Other Agency (specifiy)
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