Apply Apply General Information Name:*FirstLast Phone:* Email:* Date of Birth:*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Social Security Number (XXX-XX-XXXX)* Gender:*MaleFemaleOther Race:*WhiteBlack or African AmericanAmerican Indian / Alaska NativeAsianNative Hawaiian / Other Pacific Islander Ethnicity:*Hispanic or LatinoNot 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?*YesNo 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?*YesNo If no, do you possess an I-151, an I-1551 or an I-94 card stamped “Employment Authorized?”*YesNo If you are a male, have you registered for Selective Service?*YesNo Are you currently a recipient of SNAP or public assistance?*YesNo 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?*YesNo Do you have any food service experience?*YesNo Most Recent Employer:* Job Title:* Dates of employment (mm/yy) to (mm/yy):* Reason for leaving:*Education Highest education level completed:*Elementary/Middle SchoolSome High SchoolHigh School Diploma/GEDTechnical School CertificationBachelor’s DegreeMaster’s Degree/Ph.D. Area(s) of study/certification:*Housing Do you have a stable place to live for the next six months?*YesNo Current living situation:*living w/family or friendsrentingown homeprogram/sheltertransitional housingpermanent subsidized housingotherLegal Do you have any pending court cases?*YesNo If yes, next court date:* Do you have any current warrants?*YesNo 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?*YesNo If yes, please list each charge, the date charged and the outcome of each charge. Are you currently on any of the following:*ParoleProbationWork ReleaseHome ConfinementNone PO Name:* PO Phone:* PO Jurisdiction:*Select valueCountyStateFederalSubstance Abuse Have you ever used any of the following:*alcoholillegal drugsneither 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?*YesNo 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?*YesNo Have you ever been diagnosed with a mental illness?*YesNo 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?*YesNo Do you currently have a psychiatrist?*YesNo Name of psychiatrist and practice:* Does any of your medication make you drowsy or affect your ability to work?*YesNo If you answered yes, please explain:* Are you able to read, speak and comprehend English in a fast-paced environment?*YesNo Are you able to hear in a noisy environment with background noise from a distance of 20 feet with reasonable accommodations?*YesNo Are you able to stand for a minimum of 8 hours with two 15-minute breaks and lift 50 pounds with reasonable accommodations?*YesNo 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 agreeI do not agree Today's date:*SubmitReset