Application for Pre-Apprenticeship Construction Trades Training

BLACK CHAMBER OF COMMERCE OF LAKE COUNTY, INC.

SMALL BUSINESS & CONTRACTORS ACADEMY

APPLICATION FOR “PRE-APPRENTICESHIP CONSTRUCTION TRADES TRAINING”

Participant’s full legal name & permanent address:
LAST FIRST _____ MIDDILE______
ADDRESS _____ APT. CITY __ STATE ZIP CODE______
Home Phone: ______Work Phone: ______Cell Phone: ______
County of Residence: ______U.S. Citizen / Resident Alien: Yes____ No____
Social Security Number: _____ -______- ______Gender: M F Date of Birth: ______/_____/______
Marital Status: Single___ _ Married _____ Separated______Divorced______
E-Mail Address: ______Language spoken at home? ______

Do you have a disability requiring special assistance? Yes No Veteran? Yes No
If yes, please briefly describe: ______
Do you have a valid driver’s license? Yes____ No____ How will you travel to the program? ____________
Ethnic Background:
African American ____ Hispanic/Latino____ Latin American ____ Pacific Islander ____
American Indian ____ Asian____ Alaskan Native ____ Caucasian/White____ Other ____
Applying for enrollment in session: (Estimated Start Dates – Please Check One)
_____ Fall 2009 _____ Winter 2009 _____ Spring 2010 _____ Summer 2010 _____ Fall 2010
(Sep-Nov) (Nov-Jan) (Jan-Mar) (Apr-Jun) (Aug-Oct)
DO YOU HAVE A HIGH SCHOOL DIPLOMA OR GED? Yes______No ______(Transcripts or Certificates are required)
High School(s) Attended FROM: TO: GRADUATION DATE:
______Month/Year ______Month/Year ______Month/Year ______
City/State/Zip ______
______Month/Year ______Month/Year ______Month/Year______
City/State/Zip ______
College, Vocational or Other Training Programs: FROM: TO: GRADUATION DATE:
______Month/Year ______Month/Year______Month/Year______
City/State/Zip ______
What is your highest level of education?
____ Less than High School ____ High School/GED ____ Certificate/License
____Associates Degree ____Bachelor’s Degree ____Postgraduate Degree or work
Are you presently in school or an education program? Yes____ No_____ Type of Training______
Are you available for the training program Monday through Friday from 8:00 am until 5:00 pm? YES ____ NO ____
Select your “Building Trade” of Interest: (Check One)
____Boilermaker ____Bricklayer ____Carpenter ____Cement Mason ____Construction Craft Laborer
____Electrical Worker ____Floor Coverer ____Glazier ____Insulator ____Iron Worker
____Mechanic Tech ____Mill Cabinet ____Millwright ____Operating Engineer ____Painter
____Pile Driver ____Plumber & Pipefitter ____Roofer ____Sheet Metal Worker ____Sprinkler Fitter
How did you hear about the training program?
____BCCLC-SBCA Website ____Educational Institution ____Faith-Based Organization ____Flyer/Poster ____Job Center
____Newspaper ____Participant/Friend in Training Program ____Radio ____Social Service Agency ____Television
Current Employment Status: Full Time ____ Part Time ____ Unemployed ____ Retired ____ Seasonal ____ Temporary ____
Current Occupation: ______
Indicate Level Of Income: ____Under $10,000 ____$10,001-$15,000 ____$15,5001-$20,000 ____$20,001-$25,000
____$25,001-$30,000 ____$30,001-$35,000 ____Over $35,000
Number of Dependents? _____ Total Number of Occupants in Your Household? _____
Source of Income: ____Salary ____Self Employment ____DHS/TANF ____Child Support ____ SSI
____Pension ____Social Security ____Unemployment ____Medicare/Medicaid ____Other
Offender Status:
Have you ever been convicted of a felony or misdemeanor? Yes ____ No _____ Date of Conviction: ______
If yes, what was the conviction? (Use a separate sheet to explain if necessary)
Do you have needs that would interfere in your attendance in the program that we may assist you with? ______
Contact Information: (Please list 2 reliable contacts. Contacts must be individuals that you have daily contact with and be able to reach you if our office cannot reach you. They must have phone numbers.
Emergency Contact:
Name: ______Relationship: ______Phone: ______
Address: ______City & State: ______Zip Code: ______
Message Contact:
Name: ______Relationship: ______Phone: ______
Address: ______City & State: ______Zip Code: ______
List up to 3 personal references: (Not Family Members)
Name: ______Relationship: ______Phone: ______
Address: ______City & State: ______Zip Code: ______
Name: ______Relationship: ______Phone: ______
Address: ______City & State: ______Zip Code: ______
Name: ______Relationship: ______Phone: ______
Address: ______City & State: ______Zip Code: ______
I certify that the proceeding information is accurate to the best of my knowledge and that there is no intent to commit fraud. I understand that this information will be kept confidential and will not be released to the public. I have been advised that this information will be entered into a computerized information system and may be shared with other authorized agencies for the purpose of administering programs of these agencies. I understand that I have the right to inspect this information and initiate appropriate corrections through the agency to which I am providing this information.
Signature of Applicant:______Date:______
For Staff Office Use Only: Date: