EmailMe Form - IEC Fort Worth Apprenticeship Application

Personal Information

Name *

First MI Last Suffix

Nickname *

Date of Birth *

MM / DD / YYYY

Social Security Number *

Driver's license number *

Highest Educational Level (attained):

Sex/Gender

Male

Female

I Do Not Self-Identify

Ethnicity

Hispanic or Latino

Are you a Veteran?

Yes

No

Do you have a Disability?

Yes

No

I Do Not Self-Identify

Contact:

Address

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

Address Type

Billing

Business

Home

Primary Phone

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

Primary Phone Type

Secondary Phone Number

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

Secondary Phone Type

Email

Are you a CLC student?

Yes

No

Governmental Information

Are you legally eligible for employment in the United States?

Yes

No

Comment on my response

Are you willing to take a Drug Test?

Yes

No

Are you registered with Selective Service?

Yes

No

N/A

Within the last 7 years, have you been convicted or pleaded no contest to or received deferred adjudication for any crimes including DWI? (excluding minor traffic violations)

Yes

No

Comment on my response

Do you have a Disability?

Yes

No

I Do Not Self-Identify

Category of Disability
(Check all that apply)

Do you receive State Developmental Disabilities Agency Services (SSDA)?

Yes (SSDA)

No

Do you receive local or state Mental Health Agency services (LSMHA)?

Yes (LSMHA)

No

Do you receive services under state Medicaid HCBS Waiver?

Yes (HCBS Waiver)

No

Military Service (if applicable)

Are you eligible for Veteran Education (V.A.) Benefits?

Yes

No

Years of service

Military Separation Date

MM / DD / YYYY

Are you an Eligible Veteran?

As an Eligible Veteran, I served in the active U.S. military, naval, or air service for less than or equal to 180 days, and was discharged or released from such service under conditions other than dishonorable; or,

As an Eligible Veteran, I served on active duty for more than 180 days and was discharged or released with other than a dishonorable discharge; or was discharged or released because of a service connected disability; or as a member of a reserve

I am (a) the spouse of an Eligible Veteran who died on active duty or of a service connected disability, (b) the spouse of any member of the Armed Forces serving on active duty who is listed in one or more of the following categories and has be

I do not meet any conditions described above as an Eligible Veteran.

Are you a Disabled Veteran?

List any duties or training received in the military applicable to electrical construction

Are you a transitioning Service member?

I am a person who is on active military duty status (including separation leave) with the U.S. armed forces and within 24 months of retirement or 12 months of separation from the armed forces.

I do not meet any conditions above as a transitioning Service member.

Are you a homeless Veteran?

Yes (see full text below)

I do not meet any conditions above as a homeless Veteran.

I (a) served in the active military, naval, or air service, and was discharged or released from such service under conditions other than dishonorable, and who lacks a fixed, regular, and adequate night time residence. This includes any primary night time residence that is a publicly or privately operated shelter for temporary accommodation; an institution providing temporary residence for participants intended to be institutionalized; or a public or private place not designated for or ordinarily used as a regular sleeping accommodation for human beings.

Employment Information

Are you currently employed?

Yes

I am employed but received a Notice of Termination of Employment or my Military Separation is pending (I am within 24 months of retirement or 12 months of separation from the armed forces).

24-B. Not employed and I am seeking employment

Not employed and I am not actively seeking employment at this time.

Current/Most Recent Employer Name/Contact Information

May we contact this employer?

Yes

No

Second Most Recent Employer Name/Contact Information

May we contact this employer?

Yes

No

Third Most Recent Employer Name/Contact Information

Have you previous applied for this program?

May we contact this employer?

Yes

No

Are you a Migrant Seasonal Farmworker?

Education Information

Have you previously applied for this program?*

More Information

Highest Grade Level Completed:

Highest Education Level Completed

Have you attended a Trade/Technical/Apprenticeship School?

Specify the number of semesters you have taken in each of the following subjects:

Algebra
Geometry
Chemistry
Physics
Drafting
Electricity
List any Honors/Recognitions:
List any Skills/Training that apply to the electrical construction field that you might have.

Have you had any work-related safety training?

Yes

No

Public Assistance Information

Have you received cash assistance or other supports services from the Temporary Assistance for Needy Families (TANF) agency in the last six months?

Yes

No

If you receive TANF cash assistance, are you within 2years of exhausting lifetime eligibility?

Yes

No

I currently receive or have received SSI Assistance in the last 6 months

I currently receive or have received SSDI Assistance in the last 6 months?

I am a Ticket to Work Program Ticket Holder?

I currently receive or have received State and/or Local government assistance in the last 6 months?

I currently receive or have received Refugee Cash Assistance (RCA) in the last 6 months?

Young Parent with Dependents (check all that apply)

Young Adult Status

Young Adult Foster Care Status

Homeless Status (check all that apply)

I do not have a fixed, regular, and adequate nighttime residence.

I share the housing of other persons due to loss of housing and economic hardship.

I live in a motel, hotel, trailer park, or campgrounddue to a lack of alternative adequate accommodations.

I live in an emergency or transitional shelter.

I am waiting for foster care placement.

I have a primary nighttime residence that is a public orprivate place not designed for or ordinarily used as a regularsleeping accommodation for human beings, such as a car,park, abandoned building, bus or train station, airport, or camping ground.

I am a migratory child who in the preceding 36months was required to move from one school district toanother due to changes in the parent’s or parent’s spouse’sseasonal employment in agriculture, dairy, or fishing work.

I am under 18 years of age and have left home or lastplace of legal residence without the permission of my family.

None of the above.

Supplemental Nutrition Assistance Program (SNAP)

Other Low Income Information (check all that apply)

English Language (check all that apply)

Cultural Barrier to Employment

Single Parent (check all that apply)

Displaced Homemaker

Yes (see below)

No

47-A. I have been providing unpaid services to family members in the home and a) have been dependent on the income of another family member but is no longer supported by that income; b) am the dependent spouse of a member of the Armed Forces on active and whose family income is significantly reduced because of a deployment, a call or order to active duty, a permanent change of station, or the service-connected death or disability of the member; and am unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment.

Required Documentation

The required documentation listed below MUST be received at our admin@iecfwtc.org inbox before your application will be viewed:

– Drivers License/Photo ID
– Birth Certificate/Social Security Card
– Proof of High School Graduation/GED
– Selective Service Letter (males only)
– Copy of Electrical Apprentice License

Once your application is submitted, you will receive an email with instructions on where to send these documents. Or, you may upload these files below.

Driver's License

Social Security Card

Birth Certificate

Proof of High Graduation/GED

Selective Service Letter (males only)

Copy of Electrical Apprentice License

STAFF USE ONLY

Type in name and date that you processed the application.

Staff Name

Date Time

MM / DD / YYYY