APPLICATION CONTACT INFORMATION First Name Middle Name Initial: Last Name Street City Zipcode County: State Country Mobile Phone Number I agree to receive text messagesmobile messaging rates may apply Email Address Indicate preferred contact method:CellTextEmail OUTREACH & RECRUITMENT INFORMATION How did you hear about ANEW?Friend/FamilyPre-Apprenticeship programApprenticeship programUnionSocial mediaWorkSourceCraigslistPort jobsDOCEvent Social media (which platforms?): Event (name of the event?): PROGRAM INFORMATION Are you interested in an apprenticeship in the building and construction trades? YesNo If yes, which field are you interested in exploring or applying to (Please select all that apply):ElectricianIron WorkerPile DriverPlumbing/PipefittingLaborerElevator MechanicHVACPainterCarpentryOther Other (building/construction trade): EDUCATION INFORMATION What education level have you completed thus far? Currently attending HS or GED program9th-12th grade, no diploma or GEDHS DiplomaGED CertificateSome CollegeAssociate DegreeTechnical or Vocational CertificateBachelor's DegreeMaster's or Doctoral degree Engagement ID Contact ID: SELF IDENTIFICATION INFORMATION Your answers to many of the following questions are optional. The information is important to ANEW to guide our services based on the communities applying to our programs. This information is never shared individually, only as a statistic. For example, if 30% of our applicants are unhoused, we may use that information to partner with other service providers or apply for special funding to assist with housing costs. What is your gender?MaleFemaleTransgenderNon-binaryPrefer not to discloseOther Other (gender): How do you identify?Heterosexual (Straight)GayLesbianBisexualPrefer not to discloseOther Other (sexuality): How do you best describe yourself?American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteHispanic, Latino, Spanish originMore than one racePrefer not to disclose Do you have a Driver's License?YesNo What is your Driver's License status?ValidSuspendedNever licensed Provide your Driver License's number: Driver's License State:Please select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY If your Driver License is suspended, please explain: Please check all of the types of transportation you have access to.I own a reliable vehicleI can borrow a reliable vehicleA dependable person has agreed to drive mecity bus/public transportationpay for rides/cab, Uber, etcnone/no access to transportation Date of birth: What is your household size (including yourself)? Do you have children or dependents?YesNo If yes, how many? Please indicate their name and ages separated by comma: What is your current household type? Single adultSingle minorCouple, no childrenOne parent familyTwo parent familyFoster family What is your current living situation? Rent house or apartmentOwn residenceTransitional/temporary housingCouch surfingLive in public housing community or shelterHomelessWork release Have you experienced homelessness at any time within the last year, including currently? (more than one night staying at a hotel, motel, staying at a shelter or temporary housing program, couch surfing, sleeping in a car, a park, campsite or on the street, doubled up with another family due to hardship, or in a residence with inadequate facilities (i.e. no heat, water, electricity): YesNo Are you currently or have you ever been in foster care? Yes, before the age of 13Yes, after the age of 13NoI do not know Can you speak English?YesNo Can you read and write English?YesNo What is the primary language spoken in the home, if other than English?AmharicArabicChineseKoreanPunjabiRussianSomaliSpanishTagalogUkranianVietnameseOther Other (language): Are you currently receiving any of the following services? (Please check all that apply)SNAP/food stampsUnemploymentTANF/WorkFirstSSI/SSDIReceive government assistance for housingOther support servicesI do not receive any of the services above Please name organizations that you receive support services from: What is your immigration status?CitizenLegal ResidentImmigrantRefugee Are you a veteran?YesNoSpouse of eligible veteran COURT INVOLVEMENT Please note we ask these questions to better assist you with placement into employment. Have you ever been justice involved? (juvenile or adult)YesNo If yes, please select from below:Juvenile justice involvedMisdemeanor onlyMisdemeanor and felonyFelony only Do you have any pending court dates for any matters?YesNo List any pending court dates for any matters: Are you currently on probation or in Work Release?YesNo Probation Officer/CO Name: Probation Officer/CO Phone: Probation Duration (till when?): County (probation): Do you have check in requirements with your PO/CO?YesNo If yes, how often? EMPLOYMENT HISTORY What is your current employment status?Employed - full-timeEmployed - part-timeEmployed - seasonalCurrently on unemploymentNot employed - looking for workOther Other: Current or most recent employer: City: State:Please select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Job title: Hours worked per week: Starting Hourly Wage: Ending Hourly Wage: Start date: End Date: Reason for leaving: EMERGENCY CONTACT: Full Name Phone: Email: Relationship to student:Please select... Counselor Friend Guardian Parent Relative Service Provider INFORMATION VERIFICATION STATEMENT: Please read the statements below and input your initials. I certify that the information provided is true to best of my knowledge. I am also aware that the information I have provided is subject to review and verification by ANEW staff, and I may have to provide documentation to support the information provided. I allow release of this information for verification purposes and understand that it will be used to determine eligibility of services. I understand that receiving services is subject to availability of funding and that training and/or services are not guaranteed to me. I indicate my willingness to be screened through Washington State Connections and allow the release of this information to ANEW staff for program monitoring, verification, additional data collection, and evaluation purposes. My personal information will not be provided to any outside person or agency except where needed to determine eligibility for related programs or grant reporting purposes. Information provided on this form will not affect any benefits I am already receiving from other agencies. NON-DISCRIMINATION POLICY:ANEW follows the equal opportunity employment and training policy and does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, physical or mental ability, veteran status, military obligations, background, or marital status. Signature of Applicant: Date: By digitally writing in my name, I agree to have it act as my signature. Contact Information
