T&E Individual Worker Record Form

TRAINING & EDUCATION - INDIVIDUAL WORKER RECORD FORM

Please fill out all required fields as indicated with the red asterisk.
1. CONTACT INFORMATION

Check only if returning student
Name*

First NameLast Name
Middle Name
Date of Birth*

MonthDayYear
Date
SS#*
No Dashes and Include Leading Zeroes
E-Mail address*
example@example.com
Address*
Apt.#
City*
State*
Zip*
Cell Phone*
Home Phone
Work Phone
Original Program Start Date

MonthDayYear
Date
Agency Code

4. EMPLOYMENT STATUS

Employed - Full TimeEmployed - Part TimeNot Available for EmploymentSelf EmployedReceived a 1099 Form for WorkUnemployed: See Below
How many years have you been unemployed?
How many months have you been unemployed?
Employer’s name*
Job Title*
Hourly Rate of Pay
Average hours worked weekly
Work Location

8. Are you a Union Member or the Family Member of a Member?

YesNo
If yes:

MemberFamily member of a member
Union Affiliation
Local
9. SCHOOL AGED CHILDREN
Is the student the parent or guardian of children under the age of 21?

Parent/Guardian - YesParent/Guardian - NoSingle Parent - YesSingle Parent - No
If Yes, enter the number of children at each level:
Pre School:
Elementary:
Junior High School:
High School:
College:

Teacher Name
Class Code*
Please refer to your class sign up for the 4 digit class code. It will begin with the letters WP.
Days of Class
Time
Form Completed By:*

Clear
Date*

MonthDayYear
Date
Should be Empty: