Day Training Program Application

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Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Consent to use this number in mass text messaging *

EZ Texting

In case of emergency, notify: *

Relationship

Emergency Contact Number *

To be eligible, you must be an enrolled member of the Mississippi Band of Choctaw Indians. *

Tribal Enrollment Number

Have you ever been convicted of a felony or misdemeanor other than a minor traffic offense which has not been expunged or sealed by a court? *

If yes, list the date, city, charge and disposition

List any work experience or abilities

List any certificates or awards

Choctaw - How would you rate your language reading and writing skills

English - How would you rate your language reading and writing skills

Specify any other languages

Name of high school attended

City/State of highschool attended

Did you graduate from highschool?

GED?

Name of college attended

City/State of college attended

Did you graduate from college, or complete your degree?

Number of years in college?

Are you currently employed?

If "No," name of last employment

Is applicant receiving any other type of income?

If "Yes," please name the following source of income received

Please describe or list any disabilities or limitations that you may have. This will help provide the program information concerning yours needs in finding placement:

CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM

I certify that all of the information provided in this application is true and complete to the best of my knowledge and I authorize investigation of all statements contained in this application, including a criminal background, as applicable. I understand that any false or incomplete information may disqualify me from further consideration and may result in my immediate dismissal if discovered at a later date.

I authorize the investigation of any of all statements contained in this application and also authorize any person, school, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I have read, understand, and agree to the above statements.

Signature

Clear Signature

BACKGROUND INVESTIGATION AUTHORIZATION/ DISCLOSURE

I authorize and instruct all corporations, companies, educational institutions, persons, law enforcement agencies, Workers’ Compensation agencies, criminal, civil, and federal courts, and former employers to release information they have about me and release them from any liability and responsibility from doing so. Any copy of this authorization shall have the same authority as the original.

Signature

Clear Signature

The following information is required for background investiagation authorization/disclosure.

Name *

First

Middle

Last

Maiden or other name *

Social Security Number *

Date of birth *

Driver license number and state *

Consent to release client and/or student information

I allow and authorize the Day Training Program to discuss and/or release information from my record to other programs in the Workforce Development Program. The Workforce Development Programs are Day Training Program, Adult Basic Education Program, Vocational & Employment Services, Employment & Training Services and Vocational Rehabilitation Services.

I authorize the Program Staff members in the Workforce Development Program to discuss my information or record for the purpose of advancing my education, job training, and job placement possibilities. I further understand tha information from my record which will not identify me will be used for reporting purposes for grants and budget purposes.

Client or student name *

First

Middle

Last

Client or student signature *

Clear Signature

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