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Application Type	Pre ApprenticeApprentice Program Applicant
Last 4 Digits of SSN		Address
Last Name
First Name		City
Middle Initial		State/Zip Code
Home Phone		Email Address
Cell Phone		Verify Email

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Highest Year of Education Completed	High School(s)
High School Diploma GED DD214 From The Military Service Other Certificate From Another Source 4 Or More Years Of College 3 Years Of College 2 Years Of College 1 Year Of College
	College(s) or Vocational School(s)

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Yes	No	Have you ever been convicted of a felony?	Yes	No	Did you complete any school-to-career program?
If YES, explain the conviction. (Conviction will not automatically disqualify you.)			If YES, what Program?
			Yes	No	Have you served in the US military?
Yes	No	Do you have any trade experience?			If YES, please enter dates.
Yes	No	Have you applied with this apprenticeship program before?	Entry Date
		If YES, how many times?	Discharged
Yes	No	Have you participated in an apprenticeship of any kind?	Which Branch?
If YES, in what?
			List military training (MOS) you completed, if any.
Yes	No	Do you have a valid Driver's License?
License #

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List the reason(s) why you are applying for this apprenticeship program:

Check All That Apply

Are You Physically And Mentally Able To Safely Perform The Work Of This Trade, Either With Or Without Reasonable Accomadations? Are You Able To Get To And From Work At Various Job Sites Within The Birmingham Or Gadsden Area? Are You Able And Willing To Attend Classes Two Nights Per Week? Are You Available To Work Full-Time? Are You Able To Understand Verbal Instructions Or Warnings Given In English?

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1. Company Name		Name of Supervisor
Address		Employed From (mm/yyyy)
		Employed To (mm/yyyy)
Phone Number		Weekly Pay
State your Job Title and Describe your Work		Reason for Leaving

2. Company Name		Name of Supervisor
Address		Employed From (mm/yyyy)
		Employed To (mm/yyyy)
Phone Number		Weekly Pay
State your Job Title and Describe your Work		Reason for Leaving

3. Company Name		Name of Supervisor
Address		Employed From (mm/yyyy)
		Employed To (mm/yyyy)
Phone Number		Weekly Pay
State your Job Title and Describe your Work		Reason for Leaving

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1. Reference Name		Relationship
Reference Occupation		Address
If this reference was a supervisor, list your last title with this employer.
		Phone Number

2. Reference Name		Relationship
Reference Occupation		Address
If this reference was a supervisor, list your last title with this employer.
		Phone Number

3. Reference Name		Relationship
Reference Occupation		Address
If this reference was a supervisor, list your last title with this employer.
		Phone Number

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This apprenticeship sponsor is committed to equal opportunity for all applicants. The recruitment, selection, employment and training of apprentices during their apprenticeship, shall be without discrimination because of race, color, religion, national origin, sex or age, except the applicant must meet the minimum age requirement as specified in the standards. The JATC does not and will not discriminate against a qualified individual with a disability because of the disability of such individual.

This information voluntarily provided below is simply for equal employment opportunity commission (EEOC) purposes. This information will assist us in our efforts to provide accurate information in compliance with EEOC regulations and requirments.

Date Of Birth	Number of Dependents	Number of Years You Have Been Employed in any Occupation Full-Time to Date (Except for Military Service)
	None	None
	One	Less Than 1 Year
Gender	Two	Year 1 But Less Than 2
Female Male	Three	2 But Less Than 3 Years
	Four	3 But Less Than 4 Years
	Five	4 But Less Thans 5 Years
	Six or More	5 Years or More

Ethnicity	How did you become aware of this apprenticeship opportunity?
African AmericanCaucasian African American/CaucasianFilipino American IndianHispanic Asian Or Pacific IslanderOther Ethnic Group	Newspaper AdvertisingLocal 91 Website Television AdvertisingOther Local 91 Union Member

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You must check ALL the Boxes. If you need clarification on any item contact Local 91 JA Center.

I Understand That It Is My Responsibility To Keep The School Informed Of Any Changes In My Address Or Phone Number I Have Read And Meet The Basic Qualifications For Entry Into This Program I Understand That My Application Is Not Complete Until I Have Paid The Application Fee And Turned In All Required Documentation I Understand That Submitting An Application Is Not A Guarantee Of Employment Or Of Acceptance Into The Program I Understand That Any Intentional False Or Misleading Information Will Make Me Ineligible For The Program I Understand That If Accepted I Will Be Subject To A Drug Test I Am Legally Able To Work In The United States

I have checked all the above to indicate my understanding, and state that, to the best of my knowledge, all information provided on this form is true and accurate. I hereby grant permission to all former employers and references listed to diclose any information concerning my past employment and/or qualifications. I agree that any false statements made by me in this application shall constitute grounds for disqualification of my selection or grounds for my discharge, if false information is discovered after being selected for apprenticeship.

I hereby apply for an apprenticeship indenture with this sponsor and agree that if selected, I will abide by all Standards, Rules and Policies covered by the Indenture (Apprenticeship Agreement).

Please provide your firstname and lastname between two forward slash "/" symbols in order to indicate your agreement to these terms. (Examples: /firstname lastname/, /John Doe/)

Digital Signature

Date of Digital Signature