Laney College Oakland Green Jobs Corps Application Survey

Thank you for your interest in the Oakland Green Jobs Corps! The application period for Spring, 2010 is now closed. You may submit an application for the summer/fall course beginning in July. It will be considered in June.

This is an online application that will be submitted to the green jobs staff at Laney College upon completion. The application includes basic information, work and education history, and 4 short essay questions. If you are not able to complete the application in one setting, you may return to your application by clicking the application link on our website www.elaney.org/wp/green/ogjc from the same computer. If you have any difficulty or questions, please contact Emily Courtney at GreenJobs@peralta.edu.

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1. Contact Information

Contact Information Name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

2. Age

Age

3. Date of Birth (Mon/Date/Yr)

Date of Birth (Mon/Date/Yr)

4. Gender

Gender Male

Female

5. IF MALE AND 18-26, ARE YOU REGISTERED WITH THE SELECTIVE SERVICE?

IF MALE AND 18-26, ARE YOU REGISTERED WITH THE SELECTIVE SERVICE? Yes

No

6. IF NO, ARE YOU WILLING TO REGISTER?

IF NO, ARE YOU WILLING TO REGISTER? Yes

No

7. ETHNICITY:

ETHNICITY: African-American

White

Asian

Latino

Native American

Other (please specify)

8. ARE YOU A VETERAN?

ARE YOU A VETERAN? Yes

No

9. MILITARY BRANCH

MILITARY BRANCH

10. SERVICE DATES:

SERVICE DATES:

11. IF YOU WERE NOT BORN IN THE UNITED STATES, HOW LONG HAVE YOU LIVED HERE? (Indicate yrs and/or months)

IF YOU WERE NOT BORN IN THE UNITED STATES, HOW LONG HAVE YOU LIVED HERE? (Indicate yrs and/or months)

12. DO YOU HAVE THE RIGHT TO WORK IN THE UNITED STATES?

DO YOU HAVE THE RIGHT TO WORK IN THE UNITED STATES? Yes

No

13. HOW LONG HAVE YOU BEEN A RESIDENT OF CALIFORNIA?

HOW LONG HAVE YOU BEEN A RESIDENT OF CALIFORNIA?

14. IDENTIFICATION AND EMPLOYMENT ELIGIBILITY VERIFICATION DOCUMENTS:

	Yes	Able to furnish Upon Request?
DRIVER’S LICENSE	IDENTIFICATION AND EMPLOYMENT ELIGIBILITY VERIFICATION DOCUMENTS: DRIVER’S LICENSE Yes	Able to furnish Upon Request?
CALIFORNIA ID	CALIFORNIA ID Yes	Able to furnish Upon Request?
SOCIAL SECURITY CARD	SOCIAL SECURITY CARD Yes	Able to furnish Upon Request?
BIRTH CERTIFICATE	BIRTH CERTIFICATE Yes	Able to furnish Upon Request?

15. FOR NON-US CITIZENS

	Yes	Able to furnish Upon Request?
VISA	FOR NON-US CITIZENS VISA Yes	Able to furnish Upon Request?
GREEN CARD	GREEN CARD Yes	Able to furnish Upon Request?

16. IS THERE ANY ASSISTANCE YOU WILL NEED FROM THE PROGRAM STAFF IN ORDER TO HELP YOU TO BE SUCCESSFUL IN THE OAKLAND GREEN JOBS CORPS PROGRAM?

IS THERE ANY ASSISTANCE YOU WILL NEED FROM THE PROGRAM STAFF IN ORDER TO HELP YOU TO BE SUCCESSFUL IN THE OAKLAND GREEN JOBS CORPS PROGRAM?

17. HOW DID YOU LEARN ABOUT THIS OPPORTUNITY?

HOW DID YOU LEARN ABOUT THIS OPPORTUNITY?

1. Basic Information