Short Term Training ApplicationPlease fill in the form below and sign at the bottom. PARTICIPANT DETAILSProgram of Interest*Select a Program of InterestSelect OneAdvanced ManufacturingConstructionPublic Safety CommunicationsPrivate SecurityName* First Middle Last Primary Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* DEMOGRAPHIC AND GENERAL INFORMATIONGender*MaleFemaleCitizenship Status*US CitizenUS Permanent ResidentSelective Service*For males born after 12/31/1959RegisteredNot registeredN/AAre you Hispanic or Latino?*YesNoRace*Which one do you most closely identify with? Choose one or more. American Indian/Alaskan Native Asian Black or African American Hawaiian Native/Other Pacific Islander White Limited English*YesNoDo you consider yourself to have a disability?*YesNoAre you willing to relocate?*YesNoHighest level of education completed?* Some high school, no degree High school/GED Some college, no degree Trade/tech/vocational training Associate Bachelor's Master's Advanced graduate work/doctoral degree OTHER INFORMATIONHave you ever served in any branch of the US military?*If yes, please provide a copy of your DD214.YesNoAre you the spouse or dependent of a veteran?*If yes, please provide a copy of your military ID.YesNoDo you have eligible veteran status?*Yes, eligible veteranYes, other eligible personNoAre you currently enrolled in school?*YesNoIf yes, do you attendFull-TimePart-TimeSchool nameProgramAnticipated graduation dateAre you Pell Grant eligible?*YesNoAre you currently employed?*YesNoIf yes, where?PositionCurrent wageEmployed since Are you currently eligible for Trade Adjustment Assistance benefits?*YesNoDon't knowHow did you hear about the program?*CareerSourceGoodwillAdvanced Manufacturing RecruiterBasic Construction RecruiterPublic Safety Program RecruiterBillboardOnline SearchRadioNewspaperPostcardFriendRelativeOtherReferrals: If other or recruiter, please type in below.APPLICANT: (Attestation)I certify, by my signature, that I have read and acknowledge that the information on this form is accurate. Information is being provided to establish eligibility for training and employment services under the $2.5 million Trade Adjustment Assistance Community College and Career Training grant sponsored by the U.S. Department of Labor and is subject to all applicable Federal and State confidentiality laws. The EO data must be maintained in a manner that allows the individuals from whom the data was collected to be identified, and that ensures confidentiality.*I agreeI disagreePlease contact an advisor for assistance at 407-582-8227.M-PATH ADVANCED MANUFACTURING GRANTFor Advanced Manufacturing Applicants OnlyI hereby give permission for Valencia College and CareerSource Central Florida to obtain and/or disclose my past, present and future information or records that may be needed for eligibility determination, monitoring, internship placement and follow-up purposes. This information may include, but shall not be limited to: school records, financial aid information, grade records, attendance records, employment information, medical records, public assistance records, employment information and vocational rehabilitation assessment or evaluation tools. A photocopy/facsimile of this signed consent form may be used to obtain/release information authorized by signature on this form. It is also my understanding that any information obtained by the above organization will be held in strict confidence. I understand that I may revoke this consent at any time by providing a written statement indicating that my consent to the release of information is no longer given to the party(ies) previously granted permission.*I agreeI disagreePlease contact an advisor for assistance at 407-582-8227.I am at least 18 years of age.*YesNoBACKGROUND DISCLOSUREIn order to best prepare you for the workplace, it is important for us to better understand your background. With that in mind, have you ever been convicted of a felony or other criminal misconduct?*YesNoIf yes, please explain belowToday's Date* CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.