Automated People Mover Intake Form

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The purpose of this Intake Form is to gather information about you to assist us in connecting you with the best resources for getting you started towards building a career in construction. To get started, you will need to enroll or have graduated from a pre-apprenticeship or apprenticeship program. Through our network of community and agency partners, you will have access to a range of programs and resources available to help you address employment barriers so that you are able to achieve your construction career goals.

Date *

YYYY

First Name *

Last Name *

Zip Code *

Gender

Male

Female

Non - Binary

Date of Birth *

Home Phone Number

Cell Phone Number *

Email Address *

Education Level

0 Through 8th Grade

9 - 12 Non HS Graduate

High School/GED

Some College

BA/BS Degree

Other:

Veteran Status

Honorably Discharged

Other Than Honorable

Helmets to Hardhats Registered

Veteran Spouse

Not a Veteran

Other:

Ethnicity (Optional)

American Indian/Alaska Native

Native Hawaiian/ Other Pacific Islander

Asian

Black/African American

Hispanic/Latino

White/Caucasian

Declined to Disclose

Other:

Have you attended College?

Yes

What is your College Enrollment Status?

Active

Inactive

College Attended?

Certificate Specify

Degree Specify

Union Status

Local Trade Union

Local Union #

Apprentice Period #

Journeyman # yrs.

Are you registered with a Worksource Center/EDD/AJCC

Yes

Please list the Worksource Center/EDD/AJCC you are registered with.

Marital Status

Single

Married

Divorce

Widowed

Safety Training Completed

10 Hr OSHA

30 HR OSHA

EPA-RPP

TWIC

First Aid/CPR

40 HR HAZWOPER

80 HR HAZWOPER

OSCA

RSO

N/A

Other:

How may years of construction experience do you have?

What trades do you have construction experience in?

Have you attended a Pre Apprenticeship Training Program?

HIRELAX ARP

WINTER

YOUTHBUILD

LATTC CERTIFICATE

LATTC ARP - PROP 39

HOMEBOY INDUSTRIES - PROP 39

FLINTRIDGE CENTER - ARP

Other:

Barriers to career goals & educational success

DEPENDENT CARE

LOW-SELF MOTIVATION

HEALTH BARRIERS

EMANCIPATED FROM FOSTER CARE SYSTEM

LIMITED WORK EXPERIENCE

TRANSITIONAL OR UNSTABLE HOUSING

TRANSPORTATION

NEED FOR WORK TOOLS/EQUIPMENT

LACKS JOB SEEKING SKILLS

HOMELESS

LIMITED LABOR MARKET AWARENESS

70% OF THE LOWER LIVING STANDARD INCOME LEVEL - SINGLE $10,824.00

70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 2 PERSON HOUSEHOLD $17, 737.00

70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 3 PERSON HOUSEHOLD $24,352.00

70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 4 PERSON HOUSEHOLD $30,063.00

70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 5 PERSON HOUSEHOLD $35,475.00

Briefly explain your barriers.

Do you meet any of the following criteria? Please check all that apply.

Homeless or residing in a transitional home.

Criminal Record or Involvement with the Criminal Justice (Misdemeanor or felony)

Custodial single parent

Receiving public assistance

Lacking a GED or High School Diploma

Emancipated from Foster Care System

Reside in household with total income less than 50% of the median income (AMI)

Veteran Iraq/ Afghanistan War (1999 to present)

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