EmailMe Form - IEC Dallas -NEW Student Apprenticeship-MID 2024

Name *

First Middle Last

For which term do you seek admission?

Type of Instruction

100% Online

Hybrid

In Person

Email *

Cell Phone *

### - ### - ####

Date of Birth *

MM / DD / YYYY

Social Security Number *

Gender *

Male

Female

Participant Did Not Self-Identify

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Ethnicity *

Race *

Are you 18 years or order? *

Are you eligible for employment in the United States? *

Do you have a vehicle or reliable transportation? *

Yes

No

Are you a US citizen? *

Yes

No

Drivers License Number *

Drivers License Exp Date *

State of Drivers License *

Do you have a Disability? *

Yes, I have a Disability (or previously had a disability)

No, I don't have a Disability

I don't wish to answer

Each of the following are common Disability-Blindness, Low vision, Color blindness, Deafness, Hard of hearing, Intellectual disabilities,
Learning disabilities (e.g., dyslexia, ADHD), Epilepsy, Depression, Bipolar disorder, Schizophrenia, Autism Spectrum Disorders, Speech and Language Disorders, Diabetes, HIV/AIDS, Chronic pain conditions, Sensory Processing Disorders, Traumatic Brain Injuries (TBI), Post-Traumatic Stress Disorder (PTSD), Rheumatoid arthritis, Lupus, Deaf-Blindness, Environmental Sensitivity (e.g., Multiple Chemical Sensitivity),Age-Related Disabilities (e.g., dementia, age-related macular degeneration),
Speech and Language Disorders, Episodic Disabilities (e.g., migraines, epilepsy)

Have you ever been charged with a violation of the law which resulted in, or if still pending could result in, probation, community service, a jail sentence, or the revocation or suspension of your driver’s license (including traffic violations which resulted in a fine of $200 or more?) *

Yes

No

If yes, please explain.

Level of Completed Education *

Have you previously applied for this program? *

Yes

No

If yes, when?

Emergency Contact

Name *

First Last

Relationship *

Cell Phone *

### - ### - ####

Government/Military

Are you a Veteran of the U.S. Military? *

Non-Veteran

Veteran

Non Veteran, Other Eligible Individual

Participant Did Not Self-Identify

Are you eligible for V.A benefits? *

Yes

No

If yes, are you disabled? *

Yes

No

N/A

If YES, have you used your benefits with another institution? *

Yes

No

N/A

If YES, please list the name(s) where you V.A. benefits were used.

Male applicant, are you registered with Selective Services? *

Yes

No

Female (N/A)

If NO, please visit https:www.sss.gov/register/

Employment History

Are you currently employed? *

Yes

No

If you selected "NO", are you willing to work for a contractor who travels out of state?

Yes

No

Maybe

Name of current or most recent employer *

May we contact the listed employer *

Yes

No

Company Phone *

### - ### - ####

Start date of employment *

End date of employment (if applicable)

Job Title *

Supervisor Name *

Rate of pay *

Brief description of work performed *

Reason for leaving (if applicable)

Documents

Upload a copy of your Drivers License *

Upload a copy of your Social Security Card *

Upload High School Diploma, GED or equivalent. *

Upload Selective Services registration confirmation

Upload State Apprenticeship License *

www.tdlr.texas.gov

Upload work VISA

DD214 (if appliciaple)

IEC Dallas Enrollment

By selecting this box I authorize IEC Dallas to process my information for enrollment.

I have read and I understand the above: *

Yes

No

Standards of Apprenticeship

This document is an overview of the standards for IEC Dallas Chapter under which we operate and administer the Apprenticeship Program. The program is registered with the Office of Apprenticeship, U.S. Department of Labor.

I have read and I understand the Standards of Apprenticeship document *

Yes

No

Employment with IEC Contractor Member

To fulfill the requirement that an Apprentice work full time while attending school, IEC Dallas will arrange for you to interview with Contractor members regarding employment. Applicants for the Apprenticeship Program are to be provided no more than three (3) contractor members to interview. The applicant will not be eligible to enter the program until hired by an IEC Contractor Member.

I have read and I understand the Employment with and IEC Contractor Member *

Yes

No

Drug Screen and Background test.

If unemployed, I understand that I will have 3 days upon approval, to complete and pass a drug screen test by means of urine analysis, and background verification of Driver’s License & Social Security before registration into the IEC Dallas Apprenticeship Program. I understand that documentation will be emailed to me with location and direction for processing.

I have read and I understand the above drug screen/background process. *

Yes

No

Apprentice-Employer Relationship Commitment

While employed by the Member Contractor, the Apprentice will abide by that Contractor's policies and instructions.

The Apprentice is not to transfer from one Contractor to another. Under NO CIRCUMSTANCE will an apprentice seek a job with another Member Contractor while in the program. To do so is grounds for automatic termination from the program.

I have read and I understand the Apprenticeship-Employer Relationship Commitment. *

Yes

No

I understand that the is a non-refundable Application of $25 that must be paid before my application is processed? *

Yes

No

I HAVE READ AND UNDERSTAND THE ABOVE REQUIREMENTS OF THE IEC DALLAS APPRENTICESHIP PROGRAM AND AGREE TO EACH OF THEM AS INDICATED BY MY SIGNATURE BELOW *

Yes, I understand and agree to the terms listed above.

Signature *

Clear

Date *

MM / DD / YYYY

Credit Card Information

Name *

First Last

Card Number *

CVV *

Expiration Date *

Billing Zip *