Apply General Information Name * First Name Last Name Phone * (###) ### #### Email * Date of Birth * MM DD YYYY Social Security Number * (###-##-####) Gender * Male Female Other Race * White Black or African-American American Indian / Alaska Native Asian Native Hawaiian / Other Pacific Islander Ethnicity * Hispanic or Latino Not Hispanic or Latino Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you responsible for the care of any children/family members? * Yes No Why are you interested in the REfire Culinary Job Training Program? * How did you hear about the program? * Workforce Innovation and Opportunity Act Eligibility Are you a US citizen? * Yes No If you are a male, have you registered for Selective Service? * Yes No N/A Are you currently a recipient of SNAP or public assistance? * Yes No What is your household gross income for the last six months? * $ How many members in your household including yourself? * List names and relationships of the members in your household. * Employment Are you a veteran? * Yes No Do you have any food service experience? * Yes No Most Recent Employer: * Job Title: * Dates of employment: * (mm/yy) to (mm/yy) Reason for leaving: * Education Highest education level completed: * Elementary/Middle School Some High School High School Diploma/GED Technical School Certification Bachelor's Degree Master's Degree/Ph.D. Area(s) of study/certification: * Housing Do you have a stable place to live for the next six months? * Yes No Current living situation: * Living with Family or Friends Renting Own Home Program/Shelter Transitional Housing Permanent Subsidized Housing Other Legal Do you have any pending court cases? * Yes No Do you have any current warrants? * Yes No Please list prior conviction(s) and date(s) of convictions: * Please list dates of any time served: * Have you ever been charged with any crimes of a sexual nature, regardless of the outcome? Yes No Are you currently on any of the following: * Parole Probation Work Release Home Confinement None Substance Abuse Have you ever used any of the following: * Alcohol Illegal Drugs Neither If you are sober, what is your clean date? MM DD YYYY Health Please list all diagnosed medical conditions (e.g. high blood pressure, asthma, arthritis, diabetes, etc.): * Do you currently take medication for any of the above? * Yes No Have you ever been diagnosed with a mental illness? * Yes No Does any of your medication make you drowsy or affect your ability to work? * Yes No Are you able to read, speak and comprehend English in a fast-paced environment? * Yes No Are you able to hear in a noisy environment with background noise from a distance of 20 feet with reasonable accommodations? * Yes No Are you able to stand for a minimum of 8 hours with two 15-minute breaks and lift 50 pounds with reasonable accommodations? * Yes No Additional Information Is there anything else we should know about you? I hereby certify that all statements made in this application and any attachments to it are true. I understand that any misstatement, misrepresentation or omission of fact may cause my application not to be considered; or, if I am employed, may cause my immediate dismissal. I authorize the REfire program to verify information contained in this application and attachments. I further authorize anyone having such information to release it. I understand that if I am selected for this position and I am 18 years or older prior to employment, a criminal history screening of my background may be conducted. I also authorize the release of the information in this application to REfire partners including CareerSource Capital Region, Big Bend Homeless Coalition and employer partners. * I agree. I do not agree. Today's Date * MM DD YYYY Thank you!
