BnB Pre-apprenticeship Programs

BUILDnBEYOND Capital District LIUNA Program Questionnaire

Enrichment Training Information Sheet

PLEASE NOTE: This form is not an application for employment. Information provided will be used for data tracking and may be used to determine eligibility for training and program services.

Incomplete Applications Will Be Returned

Answer “N.A.” if a question does not apply to you.

Contact Information

First Name *

Middle Initial

Last Name *

Street Address *

Apt or Fl #, if applicable

City *

State *

Zip Code *

Home Phone

Cell Phone *

Email *

SSN *

Date of Birth *

Gender *

Married *

Children *

Which of the following best describes your racial or ethnic background? *

African American

Asian

Bi-Racial

Caucasian

Hawaiian or Pacific Islander

Hispanic or Latino

Multi-Racial

Native American

Other – Specify:

Other racial or ethnic background(s):

Are you a U.S. Citizen? *

If not, are you eligible to work in the U.S. under any of the following? *

Green Card

Work Authorization

Visa

Permanent Resident

Other (please specify):

Other eligibility to work

Income and Household Characteristics

Current housing situation *

Own

Rent

Shelter

Temporarily staying with friends/family

Halfway House/Other group housing

Other:

Other housing situation

Have you ever been homeless in the past 12 months? *

My household has the following number of people:

Adults (including me) *

My dependent children *

Other dependents *

Total people living there *

Are you currently receiving:

Cash Assistance *

Food Stamps *

Child Health Plus *

Medicaid *

Family Health Plus *

Criminal Justice History

Have you ever been arrested? *

Do you currently have a pending case? *

Have you ever been convicted? *

Have you ever been incarcerated? *

If yes, what was the length of your incarceration?

Years

Months

Release Date:

Substance Abuse History

Do you have a history of alcohol abuse? *

If yes, are you currently undergoing treatment?

Do you have a history of any other substance abuse? *

If yes, are you currently undergoing treatment?

Education, Training and Skill Assessments

What is the highest degree you have earned? *

None

High School Diploma

GED

Associates Degree

Bachelor’s Degree

Master’s Degree

Ph.D.-J.D.-M.D.

Other – Specify:

Other highest degree earned

Do you have a valid driver’s license? (Valid means not suspended or expired) *

Is your license from New York State? *

Do you have a car to drive to work every day? *

Are you a veteran? *

Are you the eligible spouse of a veteran? *

Are you registered for Selective Service? *

Please list all programs and schools you have attended beginning with the most recent first and ending with high school.

Schools/Programs Attended

Name of School/Program *

Start Date *

End Date *

Area of Study *

Certificate/Degree Granted *

Employment History

Are you currently employed full time? *

Are you currently employed part time? *

Are you currently receiving Unemployment Insurance? *

Please list your previous employment experience beginning with your most recent job.

Employment Experience

Employer *

Address *

Job Title/Duties *

Employed From *

Employed To *

Hours Per Week *

Hourly Wage $ *

Reason For Leaving *

TO BE READ AND SIGNED BY ALL APPLICANTS

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signature *

Use your mouse, finger, or touch device to write your signature.

Today's Date *

* Required Fields