Job Training Application Questionnaire:
City of Refuge 1300 Joseph E Boone Blvd. Data collected in this form is covered by our privacy policy: https://www.cityofrefugeatl.org/privacy
Email
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Home Address
*
Apartment/Unit #
Street Address
City
State
Zip Code
County of Residence
*
Please Select
Barrow
Bartow
Butts
Carroll
Cherokee
Clayton
Cobb
Coweta
Dawson
DeKalb
Douglas
Fayette
Forsyth
Fulton
Gwinnett
Haralson
Heard
Henry
Jasper
Lamar
Meriweather
Morgan
Newton
Paulding
Pickens
Pike
Rockdale
Spalding
Walton
Other
Program of Interest
*
Culinary
Cyber Security
Forklift Training
NAPA Automotive Technician
Security Guard
Solar School Installation
Welding
GED
EmployEd series (one-week digital literacy class)
Other Program of Interest
*
EmployED Session
*
Please Select
April 6-10 (5 days)
May 18-22 (5 days)
June 1-5 (5days)
What is your race?
What is Your Ethnicity?
*
Hispanic or Latino
Non-Hispanic or Latino
Race
Please choose all that apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Middle Eastern or North African
US Citizen
*
Yes
No
Highest Level of Education
*
Some high school but did not graduate
GED certificate
High School diploma
Some college (no degree)
Bachelors Degree
Have You Served in the US Military?
*
Yes
No
Are You Disabled?
*
Yes
No
Maybe
Do You Receive Public Benefits?
*
Yes
No
Have You Been Convicted of a Felony?
*
Yes
No
Gender
*
Male
Female
Prefer not to say
Are you currently employed?
Yes
No
Current Employer
*
Current Hourly Wage
*
Average Hours Worked Per Week
*
Submit
Should be Empty: