Pharmacy Technician Apprenticeship

Application Date*

Date

College Site*

Salutation*

Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender*

Cell Phone*

Please enter a valid phone number.

Home Phone*

Please enter a valid phone number.

Email*

example@example.com

Best Way to Contact*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race*

Ethnicity*

US Citizenship*

Disability*

Ex-Offender Status*

Are you a veteran?*

If a veteran, select the appropriate box*

Are you a spouse of a veteran?*

Highest Level of Education Achieved*

Program of Interest*

Are you currently attending school?*

Select the appropriate box *

School Information*

Current School Start Date*

Date

Current School End Date*

Date

What are your current educational goals?*

Are you currently employed?*

Employment Information*

Do you consider yourself under-employed?*

If considered under-employed, please select those that apply:*

Not working consistent full-time hoursWages are not sustainableNo upward mobilityWorking beneath my skill set

Are you receiving Unemployment Benefits *

Are you a NJ SNAP (Supplemental Nutrition Assistance Program) participant?*

Privacy Statement

Information collected during the enrollment process will be used for official business only to fulfill U.S. DOL’s reporting requirements. Your individual data will never be reported and data will only be used in aggregate or anonymized. You will be asked to document your employment after program completion. Additional data may be needed throughout the grant period and will be collected through questionnaires and/or surveys. Your privacy and the information you provide will be safeguarded and stored in accordance with Federal requirements.

Privacy Act

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Labor is authorized to collect information to implement the Trade Adjustment Assistance Community College and Career Training Program under 19 USUC2372 -2372a. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing this information, including social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information that is collected will be retained in the program files of the grantee and may only be released to other Department officials in the performance of their official duties.