HEO Apprenticeship Application General Background Information Last Name * First Name * Middle Name Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Cell Phone * Social Security Number THIS INFORMATION IS TRANSMITTED OVER A SECURE CONNECTION Drivers License Number * Drivers License State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Driver License Expiration Date * Are you 18 Or Older? * Yes No Have you applied for this apprenticeship program before? * Yes No When Did you Last Apply Are you a United States Citizen or legally authorized to work in the United States? * Yes No Have you ever been convicted of a felony? * Yes No A conviction record will not necessarily be a bar to acceptance, but may be relevant if job related. Please describe the situation regarding your felony Do you have prior military service? * Yes No Date of Discharge Length of Service Describe duties or experience which may be useful for consideration of apprenticeship. Sex * Male Female Prefer not to answer Veteran Status * Veteran Non-Veteran Ethnic Group * Hispanic or Latino Non-Hispanic or Latino Prefer not to answer Race * American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Prefer not to answer Emergency Contact Information Full Name * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone * Employment Status * Employed Unemployed / Not Working Current Employment Business Name * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Employment Start Date * Employment End Date (If still employed put todays date) * Hours per week * Wage / Salary * Supervisors Name * Supervisors Number * Major Activities * Machines/equipment you have used: * Job Related Experience Please describe any trade and/or construction work experience you have including specific duties you performed. APPRENTICESHIP CONDITIONS Initial * I am aware that in this construction trade, you must travel to various construction projects within numerous counties covered by this Apprenticeship program. I must have reliable means of transportation to travel to these projects. Initial * I am aware that this apprentice program has attendance of at least 144 hours per year of related training in addition to your normal working hours. I will be required to attend these related training classes without monetary compensation, even if those classes are held during a normal working day. Initial * I am aware that employment in this trade may not be full time and there may be periods of unemployment due to weather, economic conditions and other circumstances. Initial * I am aware that apprentices start at a percentage of journeyman rate and receive periodic increases. These increases are not automatic but depend on the progress made by the apprentice in on-the-job training and related training. Initial * I am aware that this occupation could involve the lifting of heavy objects, working in confined areas and working in high places. Initial * I will comply with drug testing enforcement based on employer/Apprentice agreement. Initial * Tuition/fee of $3700.00 is payable on acceptance into WCCA Apprenticeship Program. The Western Colorado Contractors Association ATC will not discriminate against apprenticeship applicants or apprentices based on race, color, religion, national origin, sex (including pregnancy and gender identity), sexual orientation, genetic information, or because they are an individual with a disability or a person 40 years old or older. The Western Colorado Contractors Association ATC will take affirmative action to provide equal opportunity in apprenticeship and will operate the apprenticeship program as required under Title 29 of the Code of Federal Regulations, part 30. I authorize investigation of all statements contained herein and authorize my former employers, references and/or schools I have attended to release any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing the same. Signature * Clear Date * I have read and understand these apprenticeship conditions and I declare that any statement in this application and other information provided is true and complete. I also authorize the verification of information provided except where specifically noted otherwise. Signature * Clear Date * Applicant’s information is confidential. Application is pending acceptance and does not guarantee placement in program until approved by WCCA and Dept. of Labor. Submit
