Name (Please Print)__________________________________________________________________________

 Address___________________________________________________________________________________

 City_______________________________State______________________Zip Code______________________

Phone No.___________________________________Social Security No._______________________________

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(The information below is requested for reporting purposes only and will not be considered in the evaluation process.)

RACE:

Caucasian__ Hispanic__ Asian or Pacific Islander__ American Indian or Alaskan Native__ Black__ Other__

Date of Birth________________________________ Male_______ Female________

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EDUCATION:

High School Graduate Yes__ No__GED__, Date_______ (GED Applicants must submit a copy of their score sheet.)

List any additional schools/courses and dates of attendance.__________________________________________

_________________________________________________________________________________________

 ________________________________________________________________________________________

VETERAN:

Are you a veteran of any branch of the armed forces? Yes___ No___ Branch____________________________

Length of service___________________________ Date of discharge_________________________________

WORK HISTORY: (Please include all types of employment whether military, part-time, full-time, temporary or permanent)

 Employer                                      Type of work                                  Location                                     Dates

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Will you be requesting credit for previous education or experience? Yes____ No_____

(If the answer is yes, you must submit the required records to the Sponsor for consideration by the Apprenticeship Committee.)

Do you have any limitations which would prevent you from performing the essential functions of the occupation for which you are applying? (If so, please explain.)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

List any additional information you wish to be considered:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

 I have read the Apprenticeship Standards of the Program to which I am applying and understand the application and selection procedure. I hereby certify that all statements and answers shown above are complete and true to the best of my knowledge.

Signature_____________________________________________ Date____________________