Reconnect Application
QUALIFICATIONS FOR THE BUILD MISSISSIPPI RECONNECT PROGRAM
Name
*
First Name
Last Name
Student must be able to provide a state or federal issued photo ID for payroll purposes.
*
I understand
Student must be physically capable to perform the essential functions of the Reconnect program, without posing a direct threat to the health and safety of themself or others.
*
I understand
Student must be physically capable of passing a third-party administered drug test.
*
I understand
Student must have a dependable means of transportation to Build Mississippi/place where classroom job-related instruction is conducted.
*
I understand
Personal Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Birthdate
*
/
Month
/
Day
Year
Date
Emergency Contact Information
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Additional Questions
Do you have previous experience or training in construction related activities? Yes or No: If Yes, please explain:
*
What do you hope to gain from participating in the Build Mississippi Reconnect Program? Please describe your goals and expectations for the program.
*
Work Experience
Begin with present job and list backwards. Please include all work experience. **If you are a student, type "Student" in the blank below.**
Employer Name
*
Dates Employed
Employer Address
Employer Phone Number
Please enter a valid phone number.
Position
Employer Name
Dates Employed
Employer Address
Employer Phone Number
Position
Upload Resume (Optional)
Browse Files
Drag and drop files here
Choose a file
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of
Trade
Please indicate the trade(s) you are most interested in:
*
Construction
Carpentry
Electrical
HVAC
Plumbing
Welding
Statistical Data
THE FOLLOWING INFORMATION IS NEEDED FOR STATISTICAL PURPOSES ONLY. IT WILL NOT BE USED FOR ANY OTHER REASON, NOR WILL IT BE DISCLOSED.
How did you hear about the Build Mississippi Reconnect Program?
*
Gender
*
MALE
FEMALE
Race/Ethnic Group
*
Caucasion/White
African American/Black
Native American
Asian
Hispanic
Pacific Islander
Other
Release of Information
To prevent unwanted solicitation by outside organizations, I hereby request that the information contained in my Reconnect application not be released to organizations unless affiliated with MCEF/Build Mississippi. In the event that information is released pursuant to a legal requirement, I would ask not to be solicited or contacted by the organization securing such information.
Signature for Release of Information
*
Acknowledgement
I have read and understand that to be eligible for the Build Mississippi Reconnect Program, I must complete this application form. All the required documents must also be returned before an interview. In consideration of the opportunity to apply to the Build Mississippi Reconnect Program, based off qualifications of Grant, I agree that any dispute arising from my application to or my participation in the Reconnect Program will be taken to arbitration, not court. By signing this application, it verifies that all the above information is true and accurate to the best of my knowledge.
Signature for Acknowledgement
*
Date Application completed
*
/
Month
/
Day
Year
Date
FINISH
FINISH
Should be Empty: