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Building Infrastructure
MIS APPLICATION


SECTION 1:    
01
Agency (Check One):
  Power for America Website    
  Other: (Please list)   
02 Social Security Number    ---   ---
  Copy of SS Card on File (will be verified by agency): 1 Yes           2 No
03 Application Date (MM/DD/YYYY)    / /
04 Last Name:  
05 First Name, Middle Initial:  
06 Street Address (Residence):  
  City:  
07 Zip:  
08 Telephone Number:   ( )   ---
09 Cell Number:   ( )   ---
10 Personal E-mail Address:  
11 Street Address (Mailing):  
  City:  
12 Zip:  
13 Eligibility to Work in the U.S.:   1 Yes           2 No
14 Birthdate: (MM/DD/YYYY)    / /
  Picture ID w/DOB on File:   1 Yes           2 No
15 Age:  
16 Selective Service:   1 Registered          4 N/A (Females; or Males 17 years of age or younger)
17 Unemployment Insurance: 3 No            1 Yes, UI Claimant           2 Exhaustee
18 Labor Force Status: 2 Not Employed        1 Employed

SECTION 2-B.3

a. Gender: i. Male           ii. Female
b. Race/Ethnicity: i.    Hispanic / Latino
    ii.   American Indian / Alaskan Native
    iii.  Asian
    iv.   Black / African American
    v.   Native Hawaiian / other Pacific Islander 
    vi.   White
    vii.  More than one race
c. Highest Grade Completed: i.     8th Grade and Under
    ii.    9th - 12th Grade
    iii.   High School Graduate or Equivalent
    iv.   1-3 Years of College, or full-time technical or vocational school
    v.    4 Years of College or More
d. Age: i.      Younger Than 18
    ii.    18-24
    iii.   25-34
    iv.   35-44
    v.     45-54
    vi.    55 or Older
e. Veteran Status: 2 No 1 Yes
f. Limited English: 2 No 1 Yes
g. Disabled: 2 No 1 Yes
h. Unemployed: 2 No 1 Yes
i. Dislocated Worker: 2 No 1 Yes
  (Individuals who are or notified of termination or lay-off or were self-employed but are now unemployed)
j. Incumbent Worker: 2 No 1 Yes
  (Individuals who need training to advance, retain, or enter full-time employment, upgrade skills to retain employment, or are part-time workers.)
k. Workers Impacted by National Energy and Environmental Policy:
2 No 1 Yes
l. In Need of Updated Training Related to the Energy Efficiency and Renewable Energy Industries:
2 No 1 Yes
m. Seeking Employment Pathways Out of Poverty and Into Self-Sufficiency:
2 No 1 Yes
n. Criminal Record: 2 No 1 Yes
o. High School Dropout: 2 No 1 Yes
p. Disadvantaged Worker within Area of High Poverty:
2 No 1 Yes
q. Individuals Impacted by Automotive-related Restructuring:
2 No 1 Yes
r. State of Residence:
s. County of Residence:
t. Military Branch:
u. Military Occupational Skills (MOS):
v. Date of Service Entry:
w. Date of Honorable Discharge:
x. Military Affiliation:
y. Disabled Veteran: 2 No 1 Yes

SECTION 3 (To be completed after enrollment)

  25 Basic Skills Pre-Test Results:
   
Reading Grade:
 
Reading Score:
 
Reading Test:
   
App. Math Grade:
 
App. Math Score:
 
App Math Test:

Applicant's certification: My signature below indicates that I have been informed of and understand the information contained on this form. I certify under penalty of perjury that all of the above information is true and complete. I agree that any information I have supplied is subject to verification. I understand that falsification of any item is grounds for termination from Utility Workers Military Assistance Program (U-MAP) and may result in action to recover any moneys paid to me while participating. (Participant will sign this document in person at time of registration)

   / /
Applicant's Signature   Date (MM/DD/YYYY)

Below for Staff Use Only

Eligibility:

  Building Infrastructure Eligible  
  X - Not Eligible - Referred to another agency for services:    
       
  Staff Comments:    
 
     / /
  Interviewer Signature   1st Review Date (MM/DD/YYYY)
     / /
  Approval Signature   Approval Date (MM/DD/YYYY)