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This application is a confidential document and will be used only to evaluate your eligibility for the ApprenticeshipWorks Program. All information will be kept strictly confidential and will only be shared with The WorkPlace staff.

You must answer ALL questions that are applicable and marked with an *. You may be required to provide documentation for any of the information entered on this application. 

DEMOGRAPHIC INFORMATION
* First Name
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Middle Name
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* Last Name
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Home Phone
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* Cell Phone
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* Email as [email protected]
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* Address 1
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Address 2
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* City or Town
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* State
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* Zip Code
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Preferred method of contact
Please list an emergency contact and their contact phone number
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* Your Date of Birth: Month/Day/Year as MM/DD/YYYY
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* Your Age
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* Gender
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* Race/Ethnicity (check all that apply)
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EDUCATION INFORMATION
* What is the highest grade in school that you have completed?
What is the name of your high school?
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* What is the date of your high school graduation? (Type NA if you did not graduate.)
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* What is your primary language?
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EMPLOYMENT INFORMATION
* Are you currently employed?
If you are currently employed, what is your employment category? (check all that apply)
* If you are not currently employed, do you receive unemployment?
What is the length of your total work experience? All jobs combined.

OTHER INFORMATION
* What trainings are you interested in?
If you selected healthcare, which program track(s) interest you?
* Do you have any of the following barriers to employment? (check all that apply) Please understand we are here to support you and ask this question to assist us in making a proper referral or plan.
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How many people are in your household (including yourself)?
* Do you or anyone in your household receive food stamps?
* How are you being financially supported?
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* Are you a U.S. citizen?
* If you are 18 or over, are your registered for the armed services?
Do you have a valid driver's license?
* What form of transportation do you use?
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Some or all of our classes may be held virtually, do you have a device at home you can use for the virtual training?
Do you have WiFi at home to use for virtual training?
What social media sites do you use?
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How did you hear about the ApprenticeshipWorks Program? (check only one)
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Once you submit your application, a staff member will contact you with more information about the program and your eligibility.
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