Healthcare, Transportation, and

Warehouse Training Initiative

* Which training program(s) are you interested in pursuing?
* Name (First and Last)
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Social Security Number
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* Date of Birth (Month/Date/Year)
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* Street Address
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* City/State/Zip
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* Phone Number (with area code)
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* Email Address (must be checked often)
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* Parish of Residence
* Are you military?
* Are you a veteran?
* Current employment status
If you are employed or underemployed, what is your place of employment?
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If you are employed or underemployed, what is your supervisor's name?
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If you are employed or underemployed, what is your work address?
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If you are employed or underemployed, what is your job title?
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If you are employed or underemployed, what is your rate of pay?
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If you are employed or underemployed, what is your start and end date?
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* Have you filed a claim to receive unemployment insurance benefits?
* Have you exhausted unemployment insurance benefits?
* List the people living in your household. List yourself first. (Include full name, Age, and Relationship to you).
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I understand that receiving the Healthcare, Transportation, and Warehouse Training Initiative tuition funds from The Coordinating & Development Corporation and Seventh Planning District Consortium Workforce Board (LWDA 70) are limited, first come first serve, and contingent upon completion of requirements for application and final approval from the training provider.

* I understand:

To determine my financial need for tuition free training, I agree to participate in LWDA 70 orientation, complete financial needs analysis, and provide a copy of credential and/or certificates of completion when issued.

* I understand:

I hereby give permission to The Coordinating & Development Corporation and Seventh Planning District Consortium Workforce Board (LWDA 70) (or its various programs) for my photograph, video, and/or digital recording to be taken at work, field trips, in the classroom, workshops, ceremonies, or in other activities sponsored by the Seventh Planning District Consortium Workforce Board (LWDA 70) and its subcontractors or training providers. I further give permission that these photographs, videos, and/or digital recordings may be used in various forms of media including, but not limited to, published in newspapers, posted on websites, posted on social media, or used in reports and publications of Seventh Planning District Consortium Workforce Board (LWDA 70), its subcontractors, training providers, The Coordinating & Development Corporation, or any federal or state agencies related to Workforce Development.

* I understand, and give permission:
* By signing below: I certify the information that I have provided on this document is true and correct to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of rights in the program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for the program.
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