Clone of DELAWARE SKILLS CENTER TRAINING APPLICATION / QUESTIONNAIRE

DELAWARE SKILLS CENTER

TRAINING APPLICATION / QUESTIONNAIRE
Course of Interest*
Gender*

MaleFemale
Full Name*

LastFirstMiddle
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone #:*

Area CodePhone Number
Cell Phone #:*

Area CodePhone Number
E-mail*
Birth Date*

MonthDayYear
LPN license number for DE:
CNA license number for DE:
Have you ever relinquished your nursing license?

YesNo
If so, what state and for what reason?
Marital Status*

SingleMarriedDivorcedWidowed
Number of Dependents:*
Is English your second language?*

YesNo
Veteran:*

YesNo
Dates Served:
Branch of Service:
Characterization of Service*

HonorableGeneralOtherN/A
Are you registered for Selective Service? (Males Only)

YesNo
If not, click on the following link to register: https://www.sss.gov/Registration/Register-Now/Registration-Form
Date you last worked as a LPN
Date you last worked as a CNA?
How many years did you work as a LPN
How many years did you work as a CNA?
Has there been any discipline assigned to your nursing license in the past?

YesNo
If yes, what state and for what reason?
Were you on probation prior to your license lapsing?
Education
Highest Grade Completed*
Degree / Certificate:*
Date Graduated:*
Have you ever attended a training course at the Delaware Skills Center?*

YesNo
If Yes, which Program?
If Yes, When (M/Y)
Have you attended any other training programs in the past 5 years?*

YesNo
If Yes, List the school and course name
____________________________________________________________
Are you a United States citizen?*

YesNo
If No, Registration #:
Do you have a valid State of Delaware driver's license?*

YesNo
License #:*
How many points are currently on your record?*
Is your license subject to revocation or suspension within the next 4 months?*

YesNo
Do you have your own vehicle for transportation?*

YesNo
Is your vehicle registered in your name?*

YesNo
Emergency Information

Please provide the Name, Address, and Phone Number (cell, work, and Home) of two people we can contact in the event of an emergency:
Person One
Full Name*

First NameLast Name
Relationship
Cell #

Area CodePhone Number
Home #

Area CodePhone Number
Work #

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Person 2
Full Name*

First NameLast Name
Relationship
Home #

Area CodePhone Number
Cell #

Area CodePhone Number
Work #

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Physical Data
General Health (check one):*

ExcellentGoodFairPoor
Have you ever had any of the following (Check all that apply):

TuberculosisHeart TroubleEpilepsy
Do you have any physical limitations?*

YesNo
If you selected yes please explain:
Are you colorblind?*

YesNo
Have you ever had back problems?*

YesNo
If you chose yes for the above question please explain:
Can you lift over 40 pounds*

YesNo
Are you currently taking any medications, prescription or over the counter?*

YesNo
If yes, please list name of medication(s) and reason for use:
Background*

Does not exclude you from program.
Have you ever been convicted of a criminal offense?*

YesNo
If yes, give date and brief explanation:
Are you now or have you ever been on probation?*

YesNo
If Yes, who is or was your Probation / Parole Officer & phone number?
Do you have any court appearances within the next 4 months?*

YesNo
If yes, give date(s) and explain:
Work Experience / Information

(Most Recent Experience First, Second. . .)
Start Date (of current job):*

MonthDayYear
End Date:

MonthDayYear
Currently Still Working?

YesNo
Job Title:*
Salary/Wage:*
Employer’s Name/Address/Phone #:*
Job Duties
Reason for leaving
Start Date:

MonthDayYear
End Date:

MonthDayYear
Job Title:
Salary/Wage:
Employer’s Name/Address/Phone #:
Job Duties
Reason for leaving
Are you presently collecting workers’ compensation or disability pay?*

YesNo
If yes, what amount are you collecting?
Are you presently collecting unemployment?

YesNo
If so, what amount are you collecting?
How many weeks do you have left to collect unemployment?
_________________________________________________________________
References
Health Care Reference

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Professional Reference

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Resume (Optional)
Is there anything that would prevent you from accepting full time permanent employment upon completion of this course and maintaining your employment for a minimum of 90 days?*

YesNo
If yes please explain in detail
How did you learn about the Delaware Skills Center?*
Name of referrer

First NameLast Name
If other, please explain
The ultimate goal and mission of the Delaware Skills Center is full-time employment upon completion of training. I understand that in order to become gainfully employed, I must be free of illegal chemical substances and willing to submit to "drug screening" by perspective employers prior to being hired. If I am found to be using or abusing illegal chemical substances, I will be unable to participate in "placement activities" and therefore not eligible for enrollment at The Delaware Skills Center
All of the information I have provided is true to the best of my knowledge and I fully understand that I will be immediately disqualified from training if the information is false or misrepresented.*

YesNo
Applicants Full Name*
Date

MonthDayYear
Media Waiver
I give my permission to NCCVT/Delaware Skills Center to use a still photograph or video image of me for use in printed publications, promotional displays, or website presentation.*

YesNo
Name

First NameLast Name
Should be Empty:

Education

Emergency Information

Physical Data

Background*

Work Experience / Information

References

Media Waiver