CONNECT TO SUCCESS

Connect To Success Application
Name*

First NameLast Name
MI
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email*
example@example.com
Prefferred Communication Method:*

HomeMobileE-Mail
Demographic Information
What gender do you identify with?*

FemaleMaleOther
Race/Ethnicity

American Indian/Alaskan NativeAsian Pacific IslandersBlack/African AmericanHispanic/LatinoNative Hawaiian or Other Pacific IslanderNon-Hispanic or LatinoWhiteOther
Individual Proficient and Able to Speak & Write in English*

YesNo
What other languages do you speak?
Transportation

Own VehiclePublic Transportation
Childcare:
Do you currently have childcare?

YesNo
Will you need childcare to attend CTS?*

YesNo
Ages of children needing childcare:

Veteran Information (Most Recent)

	Branch of Service	Date of Entry	Date of Discharge

Career & Employment History
Current Employment Status*

Full-TimePart-TimeTemporarySeasonalWorking More Than 1 JobCurrently UnemployedConsider Myself UnderemployedOther
Highest Level of Education Completed (Check All That Apply)*

Some High SchoolHigh School Diploma/GEDEarn Certification(s)/CredentialsAssociate DegreeSome College or Trade SchoolBachelor's DegreeGraduate or Prof. Degree

Work Experience (Most Recent First)

	Name & Location	Dates Employed (From/To)	Position

Current Wages & Salary (Check One)*

$0 - $25,000$26,000 - $30,000$31,000 - $35,000$36,000 - $40,000More than $40,000
Benefits (Check All that Apply)

HealthRetirementContinuing Education & TrainingLife InsuranceOther
Industry(s) Interested in Exploring Employment & Career Opportunities (Check All That Apply)

Food Production & ManufacturingWholesale & DistributionTransportation & LogisticsRetailConstructionGovernment/Social ServicesManufacturingMedical & Health CareHospitality & RestaurantsFinancial ServicesOther
Career Objectives & Goals *
Describe in 2-3 sentences what your career objectives & goals are
CONSENT FOR MARKETING (Optional)

I understand that Hope United would like to feature photos of its participating mentees (youth) in its marketing and promotional materials. I give Hope United my consent to use photos, video, images and testimonies from me and my children. I understand Hope United does not make any commitment to provide any type of monetary compensation for the use of photos, images and/or testimonies.
Signature

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Date

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PROGRAM DISCLOSURE

All of the information that you provide will be kept confidential by Hope United Community Development Corporation. This information will be used solely to assess, plan, and support your efforts toward developing career strategies and financial well-being, and will not be sold or used for commercial purposes. Hope United Community Development collects aggregated data for evaluation and reporting purposes.
Candidate for CTS Program Signature *

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Date*

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Hope United Community Development Corporation
3333 4th Avenue North
Minneapolis, MN 55412
For More Information Call: (952)240-5788 or E-Mail info@hopeunitedcdc.org
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Connect To Success Application

Demographic Information

Childcare:

Career & Employment History

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