Instructions: Please complete the following application form. The information requested in this application is needed to determine eligibility for the program and to determine additional services, which may be required by the applicant.
Date Month: January February March April May June July August September October November December Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Social Security Number
Name Phone
Address (Street and Box Number)
(Line 2, for apartment number or other, leave blank if not applicable.)
(City, State Zipcode)
Sex: Male Female Age Date of Birth Month: January February March April May June July August September October November December Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Married: Yes No Children: Yes No If yes, what are their ages?
Number of People in Household Household's Yearly Income $
Will you need child care assistance? Yes No
Are you claimed as a dependent? Yes No
Please answer the following questions as completely as possible.
1. Why are you interested in being in the MON YOUTHBUILD program?
EDUCATION
1. Last school attended
2. Highest grade completed Last year in school
3. If you did not complete high school or get your GED, why did you drop out?
4. Did you take any shop courses in school? Yes No If yes, which ones?
5. Would you consider attending training beyond Youthbuild? (i.e. college, technical
school, etc.) Yes No
6. Own a car? Yes No
7. Do you have a valid Drivers/Operators License? Yes No
8. Do you have a valid Chauffeurs/Commercial License? Yes No
CURRENT JOB
Are you currently working? Yes No
If yes, Part-time Full-time
Current hourly wage rate: $ and number of hours, on average, working during the week: Hours:
TRAINING AND WORK HISTORY
1. Have you ever been in a vocational training program? Yes No
When? (Dates)
Course of study?
Name and location of program
Did you complete the program? Yes No If no, why?
LAST JOB
Please list job history. Start with most recent and work down.
Name of company:
Address: (Street and Box Number)
Dates you worked from to
Starting Salary $ Ending Salary $
Job Title
List your duties:
Supervisor's name: and title:
Why did you leave?
List your duties
1. Do you have any construction experience? Yes No
2. If yes, was it paid experience? Yes No Please describe this experience:
ADDITIONAL INFORMATION
Have you been in the U.S. Military Service Yes No
If yes, what branch?
Rank: Discharge:
Dates:
1. Have you ever been convicted of any crime in the past? Yes No
If yes, please describe and include dates and status of case:
2. If yes, are you on probation or parole? Probation Parole No
If yes, name and phone number of
officer.
3. List what you like to do in your spare time (i.e., play basketball, go to movies, dance,
bowling, etc.)
4. In the space below, please describe yourself.
5. What do you see yourself doing 5 years from today?
6. List your top three career choices.
1. 2.
3.
7. List five personality traits that you would use to describe yourself.
3. 4.
5.
8. I do not like ...... (check all that apply)
Sitting for long periods of time
Standing for long periods of time
Seeing small things
Lifting more than 20 pounds
Using math to solve problems
Doing detailed work
Reading manuals to learn a procedure or task
Following verbal directions
Working under a deadline
Accepting criticism
Other (list)
9. In class, I.... (check all that apply)
Can be successful working at my own pace
Must have a traditional classroom setting
Do well when everyone is working on the same thing
Can work in a busy environment
Need absolute quiet to do well
10. Being on time is...(check all that apply)
Very important
Something I try to do, but not always successful at
Something I pride myself at being
Not important as long as you get the job done
11. What type of job situation(s) would you find acceptable?
Choose one: Lower pay, but in your field Higher pay, but not in your field Would not accept any job that is not in my field Would accept any position with the anticipation of getting a job in my field at some time
12. What type of wage situation(s) would you find acceptable?
Choose one: Lower pay than expected, but a chance for advancement Higher pay with little chance for advancement Lower pay with reasonable benefits Higher pay with no benefits
13. If you were offered a job that is 30 miles from home, would you accept this position?
Yes No If no, why?
14. I like to work because… Choose one: It makes me feel good about myself I like making money I would rather not, but I need to I enjoy being around people I want to advance in a career
15. Which statement(s) best describes your feelings toward Youthbuild?
My parents and/or family feel this would be good for me
It’s the only option I have at this time
It is good, but I would rather be working
I enjoy being in school more than working
I want to advance in a career
16. How long do you anticipate that it will take you to get a job after completion of training?
Choose one: 1 month 2-3 months 1 year Maybe never, depending upon job availability
17. How do you feel about taking an entry-level job? Choose one: I think I am better than entry-level It would be all right as long as promotions are in the future I expect to start at a higher-level position As long as it is my area of study
18. After you complete training, what type of job do you expect to obtain and what would be the lowest hourly wage you would work for?
19. If given the option to work for minimum wage or remain on public assistance, what would you do and why?
20. How will you get to Mon Youthbuild by 8:30?
21. Why are you interested in construction?
“I certify that the information given by me in this application is true in all respects, and I agree that the information given is found to be false in any way, it shall be considered sufficient cause for denial of acceptance into the Mon Youthbuild Program or dismissal from the program. I authorize the use of any information in this application to verify my statements, and I authorize that past employers, doctors, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.”
“I understand that nothing contained in this application or in the granting of an interview is intended to create acceptance into the program. I agree to submit to a physical examination whenever requested, and I understand my acceptance into the program and/or my continued participation in the program are subject to my successfully passing any physical examination in accordance with Mon Youthbuild policies and procedures.”
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