PASS Program Intake Form 2025-2027

PASS Program Intake Form 2025-2027
Hand written or scanned documents will not be accepted without prior WSDOT program permission. Questions are for reporting purposes only. Save this form using the format: service provider student last name first name date. Do not include commas or any other punctuation in the file name. Submit only one form per student. Multiple forms may be submitted in one email. Email to OECRPASSProgram@wsdot.wa.gov.
Service Provider
Date

MonthDayYear
Date
Name

First NameMiddle InitialStudent Name Last Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you 18 years of age or older?
Gender
How would you rate your math proficiency on a scale from 1 to 5 with 1 being very limited and 5 being very strong?
Do you have a physical social security card?
Can you life 50lbs, shovel, stand for long periods, and work in all weather?
Can you commit to attending daily with no more than 3 absences during the month-long training period?
Address

Address

Street Address Line 2

CityState

Zip
Email
example@example.com
Birth Year
What’s the highest level of education you’ve completed?
Do you have a valid Washington State driver’s license?
Are you a veteran?
Have you been involved in juvenile rehabilitation?
Have you been formerly incarcerated?
Have you ever been in the foster care system?
Ethnic Origin (check all that apply)

Other
Program Information (check all that apply)

Other
What, if any, barriers to are you facing? (check all that apply)

Other
I certify that, to the best of my knowledge, all statements on this form are true and correct. I also acknowledge that the information that I have provided is maintained for reporting purposes only.
Signature of Applicant
Date

MonthDayYear
Date
Authorized Organizational Representative
Date

MonthDayYear
Date
Title VI Notice to Public
It is the Washington State Department of Transportation’s (WSDOT) policy to assure that no person shall, on the grounds of race, color, national origin, as provided by Title VI of the Civil Rights Act of 1964, be excluded from participation in, be denied the benefits of, or be otherwise discriminated against under any of its programs and activities. Any person who believes his/her Title VI protection has been violated, may file a complaint with WSDOT’s Office of Equity and Civil Rights (OECR For additional information regarding Title VI complaint procedures and/or information regarding our non-discrimination obligations, please contact OECR’s Title VI Coordinator at (360) 705-7090.
Americans with Disabilities Act (ADA) Information
This material can be made available in an alternate format by emailing the Office of Equity and Civil Rights at wsdotada@wsdot.wa.gov or by calling toll free, 855-362- 4ADA(4232 Persons who are deaf or hard of hearing may make a request by calling the Washington State Relay at 711.

DOT Form 226-006 Revised 09/2025
Should be Empty:

PASS Program Intake Form 2025-2027

Title VI Notice to Public

Americans with Disabilities Act (ADA) Information