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Applicant Information
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Education
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Demographic Information
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References
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Previous Employment
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Military Service
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Disclaimer and Signature
TrANS Application Form
54520noel.vandiver@scc-nsn.gov 715-622-0297
Completion of this application is not a guarantee of enrollment in the TrANS Program
Applicant Information
First / Last name
Date
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YYYY
Address
Email address
Phone number
Social Security Number
Birthday
Driver’s License Number & State:
Do you currently hold a Commercial Driver’s License?
Yes
No
Have you ever been convicted of an OWI/DUI within the last 7 years?
Yes
No
If yes to the previous question, when?
Have you ever been convicted of a felony?
Yes
No
If yes to the previous question, explain:
This is used for a long answer field:
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Education
High School:
Address:
From:
To:
Did you graduate?
Yes
No
Degree:
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Demographic Information
The following information is voluntary. All information provided on this form is protected under the Privacy Act of 1974 which states that wemust explain why we are asking for information and how it will be used. Sokaogon Chippewa Community and the TrANS program uses thisinformation for reporting to its funding source. This information does not determine or affect your eligibility for the training. This data may beused for referring to additional resources, further training, and work placements.
Please answer each:
Please select the racial or ethnic background you feel best describes you:
White/Caucasian
African -American
Native American
Asian-American
Hawaiian or Pacific Islander
Two or more races
Hispanic/Latino
Are you a veteran?
Yes
No
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References
Reference 1:
First / Last name
Company:
Phone number
Address
Reference 2:
First / Last name
Company:
Phone number
Address
Reference 3:
First / Last name
Company:
Phone number
Address
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Previous Employment
1:
Company:
Phone number
Address
Supervisor:
Job Title:
Starting Salary: $
Ending Salary: $
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
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Company:
Phone number
Address
Supervisor:
Job Title:
Starting Salary: $
Ending Salary: $
Responsibilties:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
3.
Company:
Phone number
Address
Supervisor:
Job Title:
Starting Salary: $
Ending Salary: $
Responsibilites:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
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Military Service
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
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Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to getting into the TrANS program, I understand that false or misleading information in myapplication or interview may result in my release.
Signature
Clear
Date:
Verification
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