Transportation Construction Apprenticeship Readiness Training T.C.A.R.T. Cell Phone Date of Birth (mm/dd/yyyy) Gender: Male

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1 PROGRAM APPLICATION Host CBO: Applicant # Last Name Address Home Phone SS# First Name City/State/Zip Cell Phone Date of Birth (mm/dd/yyyy) Middle Initial I have the legal right to work in the US. Yes No Veteran: Yes No I received an honorable discharge: Yes No Indicate Ethnicity Hispanic or Latino Not Hispanic or Latino Gender: Male Female Indicate Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White EDUCATION Name of School City/State Graduate? Yes/No Grammar High School/GED College Vocational Other

2 EMPLOYMENT HISTORY Company Name, Address and Telephone List your last three (3) employers Date Position Salary Reason for From - Leaving To Currently employed Are you currently employed? Yes No Do you have other forms of income? Yes No If yes, what is your current monthly income? Source and monthly amount: Do you have a valid Driver s License Yes No Driver s License Number State Issued Do you have a CDL? Yes No CDL License #: Class: A B Do you have access to reliable automobile transportation? Yes No PROFESSIONAL EXPERIENCE What training or experience do you have in any of these areas? Trade Years/ Experience Trade Years/ Experience Carpenter Painter Cement Worker Electrician Equipment Operator Laborer Pipe fitter/plumber Other Are you an: Apprentice Journeyman Union/Local Number Are you interested in skill craft training?

3 Have you ever been convicted of a crime? Yes No If yes, please explain: (conviction does not exclude participation in this program) Have you ever been treated for drugs? Yes No Are you in a rehabilitation program now? Yes No Do you have an updated resume? Yes No Are you able to successfully pass a drug test? Yes No How did you hear about this Program? Website Television Radio A flyer/ad Church Community Organization From a Friend Other I,, authorize release of my personal information to The Chicago Urban League and its Partners. I also understand that The Chicago Urban League and its Partners enforce drug free policies and I agree to random drug testing. I certify that the foregoing information provided by me in this application is true and correct to the best of my knowledge. Applicant Signature Date

4 Host CBO: Applicant # Cohort # Status Code Applied Enrolled Exited Notes:

5 Applicant Name Applicant # Notes:

Total Males Females 34.4 36.7 (0.4) 12.7 17.5 (1.6) Didn't believe entitled or eligible 13.0 (0.3) Did not know how to apply for benefits 3.4 (0.

Total Males Females 34.4 36.7 (0.4) 12.7 17.5 (1.6) Didn't believe entitled or eligible 13.0 (0.3) Did not know how to apply for benefits 3.4 (0. 2001 National Survey of Veterans (NSV) - March, 2003 - Page 413 Table 7-10. Percent Distribution of Veterans by Reasons Veterans Don't Have VA Life Insurance and Gender Males Females Not Applicable 3,400,423

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