Building Infrastructure
MIS APPLICATION

SECTION 1:

Agency (Check One):

Power for America Website

Other: (Please list)

Social Security Number

--- ---

Copy of SS Card on File (will be verified by agency): 1 Yes 2 No

Application Date (MM/DD/YYYY)

/ /

Last Name:

First Name, Middle Initial:

Street Address (Residence):

City:

Zip:

Telephone Number:

( ) ---

Cell Number:

( ) ---

Personal E-mail Address:

Street Address (Mailing):

City:

Zip:

Eligibility to Work in the U.S.:

1 Yes 2 No

Birthdate: (MM/DD/YYYY)

/ /

Picture ID w/DOB on File:

1 Yes 2 No

Age:

Selective Service:

1 Registered 4 N/A (Females; or Males 17 years of age or younger)

Unemployment Insurance:

3 No 1 Yes, UI Claimant 2 Exhaustee

Labor Force Status:

2 Not Employed 1 Employed

Driver's License:


Number	State	Expiration Date (MM/DD/YYYY)

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)

Building InfrastructureMIS APPLICATION

Building Infrastructure
MIS APPLICATION