Home Phone *
Cell Phone *
County of Residence *
If you have a disability requiring special attention, please describe
Gender * Male Female
Marital Status * Single Divorced Married Widowed Separated
Do you have a valid driver’s license? * Yes No
Type of License
State of Issuance
U.S. Citizen * Yes No
Ethnic Background * Alaskan Native American Indian Asian Black/African-American White/Caucasian Hispanic Latin-American Pacific Islander Other
If you chose "Other" please put your ethnic background here
If indicated above, what field is your Degree, Certificate/License in
Are you presently in school or an educational program? * Yes No
If you chose "Yes" please put the name of school or program here
Have you participated in other training programs? * Yes No
If yes, for how long
Type of training
Have you ever participated in the HCCTP? * Yes No
If Yes, Where
Did you complete the program? Yes No
If no, state reason why
What is your current employment status? * Full Time Part Time Unemployed Seasonal Temporary Retired
Indicate your current occupational field or job title
List any other jobs held or work performed that may be related to the Construction Industry
What is your current household income level? Under $10K $10K – $15K $20K – $25K $25K – $30K $30K – $35k
Indicate the number of dependents under the age of 18 living with you in your household
Indicate the TOTAL number of occupants in your household
Have you ever been convicted of a felony or misdemeanor? * Yes No
If yes, what was the conviction charge and date?
Relationship *
Phone *
Relationship *
Phone *
Please explain, in detail, why you should be the selected candidate for this program and why? *
List what you currently know about the HIGHWAY CONSTRUCTION Industry. This includes such things, as the nature of the work, different crafts involved, working conditions, tools and equipment used, pay rates, etc. *
Give any work experience that relates to the Construction Industry. This can also include such things as minor repairs to a home, use of hand tools, servicing your car, etc. *
List what experiences, if any, that you have working in similar situations or why you would want to work in these conditions. *
Transportation
Childcare/Other
Give your specific reasons for wanting to enroll in this class. List what you want to accomplish during and after the course is over. *
Finally, as far as consideration for this program, is there anything else you would like to tell us about yourself?