MAD DADS of MPLS Workforce Development Application

Applicant Information
Name*

First NameMiddle InitialLast Name
Phone*
Email*
example@example.com
What is your preferred method of communication?*
This method will be used to keep you informed of your application status.
How did you hear about this program?*
Date of Birth*

MonthDayYear
Date
Gender (as assigned at birth)*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contacts
Name*
Phone*
Relationship to Applicant

Demographic & Household Information
Marital Status*
Race/Ethnic Background*
Country of Origin*
Primary Language*
Can you read, write, and speak English?*

YesNo
Selective Service Registration*
Are you registered with the Selective Service?
Citizenship or Immigration Status*
This information is confidential and will only be used to determine program eligibility and/or to identify other resources that may benefit you.
Household Size*
Number of occupants within the household.
Total # of Dependents*
# of Dependents in Household*
Veteran Status*
Veteran Status (cont.)*
Disability Disclosure*
Additional Disability Details:
If you elected to disclose your disability status, please feel free to include as many or as few details as you feel comfortable. This field is optional.

Background Information
Are you a current recipient of public assistance from any of the following programs provided by the State of Minnesota? Please select all that apply.*

SSISSDISNAPTANF/MFIPRefugee AssistanceDiversionary WorkGeneral AssistanceI do not receive public assistance from the State of Minnesota.
Are you or other members of your family current or past participants of any MAD DADS programs or services?*

Have you ever pled guilty, no contest to, or been convicted of a misdemeanor or felony?*
Please provide date(s) and details:*
If you are unsure of dates, please provide an estimated date and related details to the best of your knowledge.

Education Information
Highest Level of Education Completed:*
Completion Date*

MonthDayYear
If you do not know the exact day, please use the first day of the month in the year of completion.
Are you currently enrolled as a student?*
Do you currently hold any professional licenses or certifications?*

YesNo
Professional Licenses and Certifications*
List any relevant professional certifications or licenses (including issuing body and expiration date, if applicable).

Additional Information
Are you 18 years of age or older?*

YesNo
Have you had a valid MN Driver's License for the past two years?*
Do you currently have a valid MN Class A Permit?*
Class A Permit Expiration Date*

MonthDayYear
Date
Are you able to lift 50 lbs. and work outside in a variety of conditions?*

YesNo
Would you like to disclose any mental or physical health-related issues that would enable us to serve you better?*

YesNo
Mental or Physical Health-related Issues
Please share details of any relevant mental or physical health-related issues you'd like us to consider.
IMPORTANT (PLEASE READ): Please review all information for accuracy prior to submitting your application. Please allow 5-7 business days for review, afterwhich you will be contacted with an update.

Upon qualification, you will be asked to provide copies of one or more of the following documents:
- Social Security Card
- Birth Certificate
- Valid MN Identification
- Valid MN Drivers License
- Valid U.S. Passport
I acknowledge that the information I have provided above is true and accurate to the best of my knowledge.*

Yes
Should be Empty:

Applicant Information