Application for Services

If you or any members of your household are currently receiving any of the following, please fill in the total amount per month:

You have requested that certain information about you be provided to you by email, face book and/or texting. Before Southwest Minnesota Private Industry Council, Inc. will communicate with you in these forms of technology containing non-public data, you must read and agree to the following risks and conditions of use. 1. Risk of Using We caution clients from communicating by electronic technology. Transmitting non-public information data by these means has a number of risks that must be considered. These include, and are not limited to: electronic communication can be circulated, forwarded, and stored in numerous paper and electronic files. Electronic communication can be immediately broadcast worldwide and be received by many intended and unintended recipients. Electronic Communication can be: Sent to a misaddress It is easier to falsify than handwritten or signed documents. Backup copies may exist even after the sender or recipients have deleted their copy. Employers and on-line services have a right to archive and inspect information transmitted through their systems. Electronic communication can be intercepted, altered, forwarded, or used without authorization or detection. It can be used to intentionally or unintentionally distribute a computer virus, which can destroy or harm computer systems and electronic data. 2. Conditions of Use Southwest Minnesota Private Industry Council, Inc. will use reasonable means to protect the security and privacy of electronic information sent and received. However, because of risks outlined above, we cannot guarantee the security and privacy of electronic communication. Therefore, individuals must consent to the use of electronic communication for information. Consent to this use includes agreement with the following conditions: Applicable electronic communication to or from our clients will be printed out and made part of the client’s record. Because they are part of the record, other individuals authorized to access the records will have access to those documents. As necessary to provide service and secure reimbursement, we may forward electronic information to our staff and those who have authorized release of information. We will not, however, forward non-public electronic communication to independent third parties without your prior written consent, except as authorized or required by law. Although we will endeavor to read and respond promptly to any electronic communication, we cannot guarantee that any particular communication will be read and responded to within any particular period of time. Therefore, you should not use electronic communication for emergencies or other time sensitive matters. If your electronic communication requires or invites a response from us, and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the communication and when they will respond. You should not use electronic communication regarding sensitive medical information. You are responsible for informing us of any types of information that you desire not to be sent by electronic communication. You are responsible for protecting your password or other means of access to electronic communication. We are not liable for any breaches of confidentiality caused by your or any third party. 3. Communicating by Electronic Communication To communicate by electronic communication, you will: Avoid use of your employer’s computer or other computer easily accessible to others. Inform us of changes in your electronic communication address. Put your full name in the body of the communication. Avoid placing any private information on the subject line of the communication. Review the electronic communication to make sure that it is clear and that all relevant information is provided before sending to us. Take precautions to preserve the privacy of the communication, such as using and safeguarding your password. Withdraw consent only by written communication to our agency. Acknowledgement and Agreement I acknowledge that I have read and fully understand this consent form. I understand the risk associated with electronic communication between Southwest Minnesota Private Industry Council, Inc. and me, and consent to the conditions outlined herein. I agree to the instructions for electronic communication outlined here, as well as any other instructions that Southwest Minnesota Private Industry Council, Inc. may impose to electronic communication. Finally, I agree that because of my written agreement that use of electronic communication to communicate with me concerning non- public data is reasonable and proper way to communicate with me and protect my privacy.

When you receive services from state or federally funded programs, we will ask you for information about yourself. The data we are asking you to provide about yourself is considered private data by Minnesota Statute 13.47 subdivision 2. In order to collect and use this data we must tell you why we need the data, how we intend to use it, and any outcomes you may experience if you supply the information or not. You may refuse to supply any or all of this information. You are not legally required to provide information about yourself. However, if you do not supply sufficient information about yourself, it may limit our ability to provide services to you. Your information may be shared with other government entities that have a legal right to this data including the U.S. Department of Labor, the Office of Higher Education, the Office of the Legislative Auditor, the State Auditor, employment and training service providers, and welfare agencies. Your information may also be shared by court order. For more information about DEED Data Practices, visit https://mn.gov/deed/about/what-guides-us/privacy/. Types of personal information you might be asked to provide and why we need it: Social Security Number (SSN): Your SSN is requested to identify you as a unique individual, to find wage data, and to help us evaluate the performance of our programs; Name, address, birth date, and contact information: This is used to identify and contact you and to evaluate our performance; Age, gender, ethnicity, race, disability, and economic status: Demographic information is collected to help determine if you are eligible for additional assistance and to evaluate our performance; Veteran status: Veteran status is asked to determine if you are eligible for priority services and to evaluate our performance; Other personal information, such as school records, job skills and work history: Education and work history is used to help plan your employment and training goals and to evaluate our performance.