Applicant
PARTICIPANT CENTRIC EMPLOYER DRIVEN
REGIONALLY FOCUSED
PROVIDING OPPORTUNITIES FOR PEOPLE TO SUCCEED
Preliminary Form Questions This form will help our staff better understand your needs. If you ever have a question, please do not hesitate to call. Thank you for answering these questions. PLEASE PRINT Applicant Name: _____________________________________________ SSN: ____________________ Academic ID #: ____________________ Email Address: ____________________________________________________ Best # to reach you: (
) _____________ ( ) Is this your Cell Phone? Ok to Text? Y / N
Housing Complex Name (if applicable): _________________________________ Housing Complex Unit Number (if applicable): ___________________________ Do you receive financial aid? Yes No (Do you need help applying? _______) Have you received any type of degree or certificate? (Bachelor’s, Associates or Licensed Certifications)
Yes
No
Type of degree or certification, if any? __________________________________ What is your career field interest? ____________________________(See Back) What is your anticipated graduation date? _______________________________ Have you Ranked (accepted) into this career field?
Yes
No
Have you received a letter of acceptance into the field listed above?
Yes
No
Do you attend:
UTEP
EPCC
TO BE FILLED OUT BY PROJECT ARRIBA
Classification: Freshman
Sophomore
Junior
Senior
CEO SIGNATURE – REVIEWED APPLICATION PACKET Notes:
_____________________________________________ _____________________________________________
PROJECT ARRIBA ⋅ 1155 WESTMORELAND, SUITE 235 | EL PASO, TX | 79925 | 915.843.4055 MAIN | 915.843.4078 FAX
PARTICIPANT CENTRIC EMPLOYER DRIVEN
PROVIDING OPPORTUNITIES FOR PEOPLE TO SUCCEED
REGIONALLY FOCUSED
Sponsored Careers Medical Careers • • • • • • •
Registered Nurse Licensed Vocational Nurse Physical Therapy Assistant Radiology Technician Respiratory Care Technician Diagnostic Medical Sonography Other Demand Healthcare Programs
Information Technology • • • • • • •
Computer Information Systems Computer Programming Telecommunications & Networking Microsoft Certified Systems Engineer UNIX Systems Administration Cisco Networking Training Other Demand IT Fields
Other Demand Trades • • • • •
Diesal Mechanic Welder Trucking Electricians Solar Careers PROJECT ARRIBA ⋅ 1155 WESTMORELAND, SUITE 235 | EL PASO, TX | 79925 | 915.843.4055 MAIN | 915.843.4078 FAX
Where did you attend an orientation session? Name of location and address:
How did you hear about Project ARRIBA?
PROJECT ARRIBA
1155 Westmoreland, Suite 235 El Paso, Texas 79925 (915) 843-4055 Fax: (915) 843-4078
/
/
/
/ /
Date: (MM/DD/YYYY) /
PLEASE COMPLETE THIS ENTIRE FORM. THIS INFORMATION IS FOR THE USE OF PROJECT ARRIBA ONLY AND WILL NOT BE RELEASED TO ANY OTHER AGENCY WITHOUT YOUR CONSENT. IT IS NEEDED TO DETERMINE YOUR QUALIFICATIONS AND HELP US UNDERSTAND YOUR NEEDS. NOTE: COMPLETION OF THIS APPLICATION DOES NOT OBLIGATE YOU NOR PROJECT ARRIBA.
TYPE
c NAME (Last, first, MI, Jr., Sr., III, etc.)
d Social Security#
E-Mail Address
e
Academic ID #
SEX
OR PRINT
/
/
/
f IF MALE, HAVE YOU REGISTERED WITH SELECTIVE SERVICE?
YES
/
NO
M F
N/A
RESIDENCE ADDRESS
g
NUMBER AND STREET (APT NO.)
CITY
COUNTY
/
/
STATE AND ZIP /
PERMANENT MAILING ADDRESS
h
NUMBER AND STREET (APT NO.)
CITY
COUNTY /
/
i HOME PHONE k ALTERNATE PHONE CONTACTS:
(10)
(12)
STATE AND ZIP /
j
/ DATE OF BIRTH (MM/DD/YYYY) FIRST NAME (AREA CODE) PHONE NUMBER
/
LAST NAME First:
/
/
Second:
/
/
(11)
/
/
ETHNIC GROUP WHITE (Not Hispanic) BLACK (Not Hispanic) HISPANIC ASIAN OR PACIFIC ISLANDER NATIVE AMERICAN CHECK ALL THAT APPLY EDUCATIONAL
STATUS
SOME COLLEGE
IF YOU HAVE ATTENDED ANY VOCATIONAL TRAINING, PLEASE IDENTIFY THE PROGRAM:
CHECK ONE
DID YOU COMPLETE ABOVE TRAINING? IF NOT, PLEASE EXPLAIN:
HIGH SCHOOL GRADUATE
GENERAL EQUIVALENCY DIPLOMA (GED)
CITIZENSHIP
US CITIZEN REFUGEE PERMANENT RESIDENT (I-551) OTHER ELIGIBLE NON-CITIZEN
(NO. OF HOURS _________)
HIGHEST GRADE COMPLETED (_________)
CHECK ONE
YES
NO /
/
PROFICIENT IN ENGLISH: READ
WRITE
SPEAK
Have you been enrolled in a government funded program in the past year? (Check One) YES CHECK ALL THAT APPLY FAMILY STATUS: I AM.... (15) NUMBER OF DEPENDENTS MARRIED WITHOUT CHILDREN NO. OF DEPENDENTS MARRIED WITH CHILDREN AGE 5 OR LESS: A SINGLE PARENT NO. OF DEPENDENTS LIVING WITH RELATIVES (EXPLAIN) OVER AGE 5: SINGLE (INCLUDES DIVORCED & SEPARATED) LIVING (16) ARE YOU WILLING TO TAKE ON MY OWN (NOT DEPENDENT ON FAMILY) A DRUG TEST? (CIRCLE ONE) REMARKS (IDENTIFY REMARKS BY ITEM NUMBER AND ENTER EXPLANATION. IF MORE SPACE IS NEEDED, CONTINUE ON A SEPARATE SHEET OF PAPER.): (13) (14)
NO ENTER NUMBER
0 0 YES
NO
/
/
Project ARRIBA prohibits discrimination against applicants, participants and employees on the basis of race, color, sex, religion, national origin, age, disability, sexual orientation, or any other legally protected characteristic. Digital Application Form Ver. 1.0 Release Date: 7/3/2006
Page 1 of 2
(17)
WHICH OF THE FOLLOWING STATEMENTS APPLIES TO YOU? (CHECK AS MANY ITEMS AS NECESSARY TO EXPLAIN YOUR BACKGROUND)
PAGE TWO CHECK ALL THAT APPLY
ANSWERS TO QUESTIONS CANNOT DISQUALIFY YOU FROM THE PROGRAM AND MAY HELP YOU QUALIFY.
SINGLE PARENT HOMEMAKER WHO HAS NOT WORKED IN SEVERAL YEARS AND NOW NEEDS EMPLOYMENT DUE TO LOSS OF SPOUSE OR SUPPORT WELFARE RECIPIENT CONVICTED OF A FELONY OR A MISDEMEANOR (DO NOT INCLUDE TRAFFIC TICKETS) HAVE NOT WORKED IN THE LAST TWO YEARS HAVE NOT HELD THE SAME JOB FOR MORE THAN SIX MONTHS HAVE NEVER WORKED HAVE NEVER ATTENDED VOCATIONAL TRAINING ATTENDED VOCATIONAL TRAINING, BUT WAS NEVER ABLE TO FIND A JOB USING THE SKILL IN WHICH I WAS TRAINED DISABLED (PHYSICAL OR MENTAL DISABILITY, INCLUDING DRUG OR ALCOHOL DEPENDENCY) / HAVE SERVED IN THE U.S. ARMED FORCES: INDICATE BRANCH: / DATE OF SEPARATION: mm/dd/yyyy
(18)
/
/
EMPLOYMENT INFORMATION -- LIST JOBS YOU HAVE HELD IN THE LAST THREE YEARS:
COMPANY NAME AND ADDRESS
JOB TITLE / DUTIES /
(19)
/
DATES OF EMPLOYMENT (MM/DD/YYYY) to (MM/DD/YYYY) / / to /
/
/
/
to
/
/
/
/
/
to
/
/
/
/
/
to
/
/
/
/
/
to
/
/
LIST ANY SKILLS OR EXPERIENCE YOU HAVE THAT MIGHT BE USEFUL IN A JOB:
/
/
/
/
/
/ PLEASE LIST ANY OCCUPATIONAL INTEREST(S) YOU HAVE: /
(20)
/
CHECK ALL THAT APPLY: IF YOU RECEIVE ANY PUBLIC ASSISTANCE, INDICATE WHICH AGENCIES
AFDC / TANF FOOD STAMPS SSI
GENERAL ASSISTANCE REFUGEE ASSISTANCE OTHER (PLEASE SPECIFY)
(21) LIST ALL HOUSEHOLD FAMILY MEMBERS & YEARLY INCOME (GROSS) OF EACH:
(INCLUDE YOURSELF)
FULL NAME
RELATIONSHIP
AGE
INCOME
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/ /
/
TOTAL:
(22) REFERRED BY (PLEASE INDICATE AGENCY) : SIGNATURE OF APPLICANT _____________________ Date____/____/____
/
0
PROJECT ARRIBA USE ONLY: Entered by: ______
City Council District Number: __________ Date____/____/____
Digital Application Form Ver. 1.0 Release Date: 7/3/2006
REGIONALLY FOCUSED
PROVIDING OPPORTUNITIES FOR PEOPLE TO SUCCEED
Preliminary Form Questions This form will help our staff better understand your needs. If you ever have a question, please do not hesitate to call. Thank you for answering these questions. PLEASE PRINT Applicant Name: _____________________________________________ SSN: ____________________ Academic ID #: ____________________ Email Address: ____________________________________________________ Best # to reach you: (
) _____________ ( ) Is this your Cell Phone? Ok to Text? Y / N
Housing Complex Name (if applicable): _________________________________ Housing Complex Unit Number (if applicable): ___________________________ Do you receive financial aid? Yes No (Do you need help applying? _______) Have you received any type of degree or certificate? (Bachelor’s, Associates or Licensed Certifications)
Yes
No
Type of degree or certification, if any? __________________________________ What is your career field interest? ____________________________(See Back) What is your anticipated graduation date? _______________________________ Have you Ranked (accepted) into this career field?
Yes
No
Have you received a letter of acceptance into the field listed above?
Yes
No
Do you attend:
UTEP
EPCC
TO BE FILLED OUT BY PROJECT ARRIBA
Classification: Freshman
Sophomore
Junior
Senior
CEO SIGNATURE – REVIEWED APPLICATION PACKET Notes:
_____________________________________________ _____________________________________________
PROJECT ARRIBA ⋅ 1155 WESTMORELAND, SUITE 235 | EL PASO, TX | 79925 | 915.843.4055 MAIN | 915.843.4078 FAX
PARTICIPANT CENTRIC EMPLOYER DRIVEN
PROVIDING OPPORTUNITIES FOR PEOPLE TO SUCCEED
REGIONALLY FOCUSED
Sponsored Careers Medical Careers • • • • • • •
Registered Nurse Licensed Vocational Nurse Physical Therapy Assistant Radiology Technician Respiratory Care Technician Diagnostic Medical Sonography Other Demand Healthcare Programs
Information Technology • • • • • • •
Computer Information Systems Computer Programming Telecommunications & Networking Microsoft Certified Systems Engineer UNIX Systems Administration Cisco Networking Training Other Demand IT Fields
Other Demand Trades • • • • •
Diesal Mechanic Welder Trucking Electricians Solar Careers PROJECT ARRIBA ⋅ 1155 WESTMORELAND, SUITE 235 | EL PASO, TX | 79925 | 915.843.4055 MAIN | 915.843.4078 FAX
Where did you attend an orientation session? Name of location and address:
How did you hear about Project ARRIBA?
PROJECT ARRIBA
1155 Westmoreland, Suite 235 El Paso, Texas 79925 (915) 843-4055 Fax: (915) 843-4078
/
/
/
/ /
Date: (MM/DD/YYYY) /
PLEASE COMPLETE THIS ENTIRE FORM. THIS INFORMATION IS FOR THE USE OF PROJECT ARRIBA ONLY AND WILL NOT BE RELEASED TO ANY OTHER AGENCY WITHOUT YOUR CONSENT. IT IS NEEDED TO DETERMINE YOUR QUALIFICATIONS AND HELP US UNDERSTAND YOUR NEEDS. NOTE: COMPLETION OF THIS APPLICATION DOES NOT OBLIGATE YOU NOR PROJECT ARRIBA.
TYPE
c NAME (Last, first, MI, Jr., Sr., III, etc.)
d Social Security#
E-Mail Address
e
Academic ID #
SEX
OR PRINT
/
/
/
f IF MALE, HAVE YOU REGISTERED WITH SELECTIVE SERVICE?
YES
/
NO
M F
N/A
RESIDENCE ADDRESS
g
NUMBER AND STREET (APT NO.)
CITY
COUNTY
/
/
STATE AND ZIP /
PERMANENT MAILING ADDRESS
h
NUMBER AND STREET (APT NO.)
CITY
COUNTY /
/
i HOME PHONE k ALTERNATE PHONE CONTACTS:
(10)
(12)
STATE AND ZIP /
j
/ DATE OF BIRTH (MM/DD/YYYY) FIRST NAME (AREA CODE) PHONE NUMBER
/
LAST NAME First:
/
/
Second:
/
/
(11)
/
/
ETHNIC GROUP WHITE (Not Hispanic) BLACK (Not Hispanic) HISPANIC ASIAN OR PACIFIC ISLANDER NATIVE AMERICAN CHECK ALL THAT APPLY EDUCATIONAL
STATUS
SOME COLLEGE
IF YOU HAVE ATTENDED ANY VOCATIONAL TRAINING, PLEASE IDENTIFY THE PROGRAM:
CHECK ONE
DID YOU COMPLETE ABOVE TRAINING? IF NOT, PLEASE EXPLAIN:
HIGH SCHOOL GRADUATE
GENERAL EQUIVALENCY DIPLOMA (GED)
CITIZENSHIP
US CITIZEN REFUGEE PERMANENT RESIDENT (I-551) OTHER ELIGIBLE NON-CITIZEN
(NO. OF HOURS _________)
HIGHEST GRADE COMPLETED (_________)
CHECK ONE
YES
NO /
/
PROFICIENT IN ENGLISH: READ
WRITE
SPEAK
Have you been enrolled in a government funded program in the past year? (Check One) YES CHECK ALL THAT APPLY FAMILY STATUS: I AM.... (15) NUMBER OF DEPENDENTS MARRIED WITHOUT CHILDREN NO. OF DEPENDENTS MARRIED WITH CHILDREN AGE 5 OR LESS: A SINGLE PARENT NO. OF DEPENDENTS LIVING WITH RELATIVES (EXPLAIN) OVER AGE 5: SINGLE (INCLUDES DIVORCED & SEPARATED) LIVING (16) ARE YOU WILLING TO TAKE ON MY OWN (NOT DEPENDENT ON FAMILY) A DRUG TEST? (CIRCLE ONE) REMARKS (IDENTIFY REMARKS BY ITEM NUMBER AND ENTER EXPLANATION. IF MORE SPACE IS NEEDED, CONTINUE ON A SEPARATE SHEET OF PAPER.): (13) (14)
NO ENTER NUMBER
0 0 YES
NO
/
/
Project ARRIBA prohibits discrimination against applicants, participants and employees on the basis of race, color, sex, religion, national origin, age, disability, sexual orientation, or any other legally protected characteristic. Digital Application Form Ver. 1.0 Release Date: 7/3/2006
Page 1 of 2
(17)
WHICH OF THE FOLLOWING STATEMENTS APPLIES TO YOU? (CHECK AS MANY ITEMS AS NECESSARY TO EXPLAIN YOUR BACKGROUND)
PAGE TWO CHECK ALL THAT APPLY
ANSWERS TO QUESTIONS CANNOT DISQUALIFY YOU FROM THE PROGRAM AND MAY HELP YOU QUALIFY.
SINGLE PARENT HOMEMAKER WHO HAS NOT WORKED IN SEVERAL YEARS AND NOW NEEDS EMPLOYMENT DUE TO LOSS OF SPOUSE OR SUPPORT WELFARE RECIPIENT CONVICTED OF A FELONY OR A MISDEMEANOR (DO NOT INCLUDE TRAFFIC TICKETS) HAVE NOT WORKED IN THE LAST TWO YEARS HAVE NOT HELD THE SAME JOB FOR MORE THAN SIX MONTHS HAVE NEVER WORKED HAVE NEVER ATTENDED VOCATIONAL TRAINING ATTENDED VOCATIONAL TRAINING, BUT WAS NEVER ABLE TO FIND A JOB USING THE SKILL IN WHICH I WAS TRAINED DISABLED (PHYSICAL OR MENTAL DISABILITY, INCLUDING DRUG OR ALCOHOL DEPENDENCY) / HAVE SERVED IN THE U.S. ARMED FORCES: INDICATE BRANCH: / DATE OF SEPARATION: mm/dd/yyyy
(18)
/
/
EMPLOYMENT INFORMATION -- LIST JOBS YOU HAVE HELD IN THE LAST THREE YEARS:
COMPANY NAME AND ADDRESS
JOB TITLE / DUTIES /
(19)
/
DATES OF EMPLOYMENT (MM/DD/YYYY) to (MM/DD/YYYY) / / to /
/
/
/
to
/
/
/
/
/
to
/
/
/
/
/
to
/
/
/
/
/
to
/
/
LIST ANY SKILLS OR EXPERIENCE YOU HAVE THAT MIGHT BE USEFUL IN A JOB:
/
/
/
/
/
/ PLEASE LIST ANY OCCUPATIONAL INTEREST(S) YOU HAVE: /
(20)
/
CHECK ALL THAT APPLY: IF YOU RECEIVE ANY PUBLIC ASSISTANCE, INDICATE WHICH AGENCIES
AFDC / TANF FOOD STAMPS SSI
GENERAL ASSISTANCE REFUGEE ASSISTANCE OTHER (PLEASE SPECIFY)
(21) LIST ALL HOUSEHOLD FAMILY MEMBERS & YEARLY INCOME (GROSS) OF EACH:
(INCLUDE YOURSELF)
FULL NAME
RELATIONSHIP
AGE
INCOME
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/ /
/
TOTAL:
(22) REFERRED BY (PLEASE INDICATE AGENCY) : SIGNATURE OF APPLICANT _____________________ Date____/____/____
/
0
PROJECT ARRIBA USE ONLY: Entered by: ______
City Council District Number: __________ Date____/____/____
Digital Application Form Ver. 1.0 Release Date: 7/3/2006
