Brownfields Application

Brownfields: Program Application
Name:*

First NameMiddle NameLast Name
Age (Program: 18-24)*
Age
Date of Birth:*

MonthDayYear
Date
Gender at Birth:*
Race/Ethnicity:*
Phone Number:*

Area CodePhone Number
E-mail Address:*
Your Email Address
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Household*
Household Income:*

$1 - $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - $40,000$40,001 - $50,000Above $50,000
Do you currently have a license or permit to drive?*
Do you have reliable and available transportation? *
Note: Some classes are held at JCTC Southwest Campus
Do you already have your CDL permit?*
Classes run from 7am -5pm on Monday- Friday for 5 weeks. Can you commit to attending all the classses?*
Do you have any other certifications or have you completed any other trainings that apply to this field of work? List them below:
Do you have any certifications or licenses related to construction, renovation, or hazardous materials? Please list below if so.
Have you previously participated in any job training programs? If yes, which ones?
Which of our training programs are you most interested in?

Asbestos Abatement WorkerCPR/First Aid CertificateEPA RRP - Initial CertificationLead Renovator Training40-Hour HAZWOPER8-Hour HAZWOPER SupervisorCDL CertificateDOT Hazardous Materials
Why are you interested in this training program?*
Are you able to commit to the full duration of the training program?*
Do you have any scheduling conflicts or obligations that might interfere with the training?*
Are you able to commit to the full duration of the training program?*
Describe any relevant skills you already possess.*
What specific skills do you hope to gain from this training?*
What are your career goals after completing this training? *
How do you plan to use the skills and certifications gained from this program?*
Do you have any medical conditions or physical limitations that might affect your ability to participate in the training?*
Is there anything else you would like us to know about you?*
I was referred to this program by:
How did you learn about this program?
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MEDIA RELEASE: Photos/ Videos are taken of the program throughout the year and may include you directly or indirectly. These photos/ videos may be published through our website, social media, news bulletins, advertising and other media. Please indicate your consent and release of your image/ likeness to be used without notice and additional permission.*

YESNO
NEXT STEPS:

Your application will be reviewed and you will be contacted by a member of our team through email. Please watch your email closely.

You will be expected to bring the following documents with you to the initial interview. Get these documents ready to be fully prepared!

1) Proof of Income (Medicaid card, eligibility letter from SNAP, etc)

2) Drivers Permit/ License (if you have one)

3) Social Security Card

4) Birth Certificate

Once these documents have been provided, you will be scheduled to take a TABE Test (academic assessment test), Drug Test and complete a Background Check.

Your initials below signify that you understand and agree to this process. We look forward to meeting you!
Initials: *
Date*

MonthDayYear
Date
Should be Empty:

Brownfields: Program Application

RELEASES