Apply – Refire Culinary

General Information

Name:*

First

Last

Phone:*

Email:*

Date of Birth:*

day

month

year

Social Security Number (XXX-XX-XXXX)*

Gender:*

Male

Female

Other

Ethnicity:*

Hispanic or Latino

Not Hispanic or Latino

Mailing Address:*

Street Address City State / Province / Region Postal / Zip Code

Are you responsible for the care of any children/family members?*

Yes

If yes, please explain:*

Why are you interested in the REfire Culinary Job Training Program?*

How did you hear about the program?*

Workforce Innovationand Opportunity Act Eligibility

Are you a US citizen?*

Yes

If no, do you possess an I-151, an I-1551 or an I-94 card stamped “Employment Authorized?”*

Yes

If you are a male, have you registered for Selective Service?*

Yes

Are you currently a recipient of SNAP or public assistance?*

Yes

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

Do you have any food service experience?*

Yes

Most Recent Employer:*

Job Title:*

Dates of employment (mm/yy) to (mm/yy):*

Reason for leaving:*

Education

Area(s) of study/certification:*

Housing

Do you have a stable place to live for the next six months?*

Yes

Legal

Do you have any pending court cases?*

Yes

If yes, next court date:*

Do you have any current warrants?*

Yes

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

If yes, please list each charge, the date charged and the outcome of each charge.

PO Name:*

PO Phone:*

PO Jurisdiction:*

Substance Abuse

Have you ever used any of the following:*

alcohol

illegal drugs

neither

If yes, list all applicable substances:*

Date of last alcohol use:*

Date of last drug use:*

How often do/did you use alcohol and/or drugs?*

Describe the volume of your substance use:*

Have you ever enrolled in a Substance Abuse Treatment Program?*

Yes

If yes, which one(s)?*

Date(s):*

If you are sober, what is your clean date?

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

Have you ever been diagnosed with a mental illness?*

Yes

If yes, please list all diagnosed mental health conditions (e.g. Depression, Schizophrenia, ADHD, etc.):*

Do you currently take medication(s) for any of the above?*

Yes

Do you currently have a psychiatrist?*

Yes

Name of psychiatrist and practice:*

Does any of your medication make you drowsy or affect your ability to work?*

Yes

If you answered yes, please explain:*

Are you able to read, speak and comprehend English in a fast-paced environment?*

Yes

Are you able to hear in a noisy environment with background noise from a distance of 20 feet with reasonable accommodations?*

Yes

Are you able to stand for a minimum of 8 hours with two 15-minute breaks and lift 50 pounds with reasonable accommodations?*

Yes

Is there anything else we should know about you?

Upload any additional files (resume, etc.)

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:*