telework application.pdf

8/3/2019 Telework Application.pdf

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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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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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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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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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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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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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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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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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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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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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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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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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telework application.pdf

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