Work Force Development Application
Name:
*
First Name
Last Name
SSN (last 4 Digits)
*
ssn
Date of Birth
*
-
Month
-
Day
Year
Date
Race?
*
Gender?
*
Male
Female
Program Applying For
*
Operation Stash
Operation Kickstart
“It’s My Time to Shine” Program
Personal Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
*
Marital Status
Married
Divorced
Single
Widowed
Number of Dependents
Education
High School Diploma
*
Yes
No
Location
State
Other (schools attended, training or certifications received, licenses obtained)
Work and Special Competencies
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Special talents, skills, training (languages, artistic skills, computer skills, special licenses, significant achievements, etc)
Do you have a valid drivers license?
*
Yes
No
Do you have transportation?
*
Yes
No
Are you receiving government assistance?
*
Yes
No
Are you receiving SSI or SSDI?
*
Yes
No
Are you receiving Child Support?
*
Yes
No
Legal Background
List all law violations below (felonies, misdemeanors, DUI’s, open traffic tickets). NOTE: Please answer this section accurately. We need the data regarding your law violations for program assessment purposes only. There are numerous services available for ex-felons and we will strive to ensure that you are given every opportunity for Self-Enrichment and Empowerment.
*
I have no law violations to report
I have law violations to report.
Who Referred You?
Contact Name
*
Agency
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Notes
Liability Release
On date of signing, intending to be legally bound hereby, the undersigned agrees and does hereby release from liability and to indemnify and hold harmless Soul Winners Connection, Inc., and any of its employees or agents representing or related to all entities. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for this Program. The undersigned further agrees to abide by all the rules and regulations promulgated by Soul Winners Connection, Inc. and/or its affiliate groups and vendors throughout the duration of the program.
Applicant Signature
By typing my name below, I am digitally signing my application.
Digital Signature
*
First Name
Last Name
Signature
Todays Date
*
-
Month
-
Day
Year
Date
Submit
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