Address: Street Address Apartment/Unit # City State ZIP Code Phone: Email
Date of Birth: Social Security No.:
Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO
Have you ever been convicted of a felony? YES NO
If yes, explain: Children
Number of Children: Child 1 DOB: Child 2 DOB: Child 3 DOB: Education Information High School: Address:
From: To: Did you graduate? YES NO Diploma:
GED: Testing Center:
Year: College: Address: From: To: Did you graduate? YES NO Degree:
References
Please list three personal, professional, academic, or spiritual leader references.
Responsibilities:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?
Military Service
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:
Personal Financial Status
Current Monthly Income (including assistance from parents, friends or other source)
From work, before taxes:
From parents, child support, or other sources:
TANF Cash Assistance from Government: 1 (Excellent), 2 (Very Good), 3 (Good), 4 (Poor)
How would you rate your credit:
Lifestyle Status
Marital Status:
With Whom Do You and Your Children Live: (Parents, Friends, Boyfriend, Relatives, Other)
Career Plans
What are your career goals?
Past Accomplishments
Please tell us about your past accomplishments: awards, participation in clubs, youth organizations, volunteer experiences.
Why do you believe you would be a candidate for this program?”. We recommend you write your answer in a separate document and submit with your application (answer can include: financial, health, career, family, and/or life hopes and dreams)
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature:
Date: