Please Check One
INDIANAPOLIS OFFICE:
GARY OFFICE:
Full Name:
(Last Name)
(First Name)
(M.I.)
Address:
(Address)
(Last 4 of Social Security #)
(City)
(State)
(ZIP)
(County)
Contact:
Net Access:
--Select--
Yes
No
(Phone #)
(Cell #)
(Email Address)
(Yes/No)
Applicant Info:
(Age)
(Date of Birth)
(City of Birth)
List 3 Apprenticeships That Interest You:
1.
2.
3.
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
Do you own a car?
--Select--
Yes
No
--Select--
Yes
No
If you have
no
car, whose car will you use?
Are you registered with selected service?
--Select--
Yes
No
Are you a Veteran?
Total Active Duty (not including reserve time) If Applicable:
--Select--
Yes
No
From:
To:
Do you have a
Valid Indiana
Drivers License?
Valid CDL License?
--Select--
Yes
No
--Select--
Yes
No
Educational Background
High School:
--Select--
None
9
10
11
12
Graduated
(School Attended)
GED
--Select--
Yes
No
--Select--
Yes
No
(GED)
(Scores Avail.)
(GED Completion Date)
College:
--Select--
None
1
2
3
4
More
Graduated
(Years Attended)
(Other Schools Attended)
Have you taken and passed one (1) full year of High School Algebra?
--Select--
Yes
No
Have you taken any of the following courses: (check all that apply)
Geometry
Trig.
Calculus
Physics
Other
Personal Information
(
Confidential pursuant to: 20CFR (1977) Ch. 5Sec.604.16:IC22-44-19-6.IC4-6
)
Please Complete This Section For Our Records. Thank You.
Have you ever been arrested for a felony:
--Select--
Yes
No
Have you ever been convicted of a felony:
--Select--
Yes
No
Have you ever been through this program before:
--Select--
Yes
No
Who referred you to this program:
--Select--
None
Friend
Relative
Organization
Name of Source That Referred You:
--Select--
Yes
No
--Select--
Yes
No
--Select--
Yes
No
--Select--
Male
Female
(Height)
(Weight)
(Married)
(Single)
(Divorced)
(Gender)
Ethnicity:
African American
Asian
White/Caucasian
Native American / Alaskan Native
Hawaiian / Pacific Islander
Hispanic
Other
Did Not Identify
Previous Employment
(Beginning with the most recent)
Employer Name:
Date of Hire:
End Date:
Monthly Wage:
Reason For Leaving:
Type of Business:
Job Title:
Employer Name:
Date of Hire:
End Date:
Monthly Wage:
Reason For Leaving:
Type of Business:
Job Title:
Employer Name:
Date of Hire:
End Date:
Monthly Wage:
Reason For Leaving:
Type of Business:
Job Title:
Other Contacts Information
Please List the Names and Addresses of Two Relatives and/or Friends:
(Name)
(Address)
(Phone)
(Name)
(Address)
(Phone)
Other Contacts Information
I certify that my answers are true and complete to the best of my knowledge by Checking This Box: