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Pre-screening Form for HSE/Certifications
* Indicates required question
Name
*
Your answer
DOB:
*
MM
/
DD
/
YYYY
Address:
*
Your answer
City, State, Zip
*
Your answer
Phone:
*
Your answer
Email address:
*
Your answer
Are you employed
*
Yes
No
Required
Employment Status
*
Full-Time
Part-Time
Temporary
If employed, where and hourly rate.
Your answer
Do you have a valid driver's license?
*
Yes
No
Which program are you interested in?
*
EMT
CNA
CDL - A
CDL - B
School Bus / CDL-B
CNC
Core Construction - Bedford
Welding - Lyons or Linton
Welding - Bedford
CCMA - Lyons
CCMA - Sullivan
High School Equivalency Diploma / HSE
Construction Math for IKORCC - Union Referral for Carpenter or Floor Coverer/Layer
Required
Do you have your CDL Permit?
*
Yes
No
N/A - Not requesting CDL Training
Do you have a high school diploma / GED/ HSE?
*
Yes
No
What was the last grade you completed if no diploma?
Grades 1-6 - Elementary
Grades 7-8 - Jr. High
9th
10th
11th
Clear selection
Do you have a college degree
*
Yes
No
Did you have an IEP or 504 with special education services while in school?
Yes
NO
Don't Know
Clear selection
What school did you last attend?
Your answer
Do you prefer nights or days?
*
Nights
Days
Either
First Available
How did you hear about us
*
Work One / DWD
Brochure
Court/Probation Referral
Employer
Friend/Relative
Our Website
Newspaper
Public Assistance
TV/Radio
Other:
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