TSP Interest Form

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* 1. Full Name

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* 2. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. Date of Birth

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* 4. Ethnicity

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

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* 5. What is the highest level of education you have completed?

Less than high school

High school diploma or GED

Some college, no degree

Associate degree (e.g., AA, AS)

Bachelor’s degree (e.g., BA, BS)

Some graduate school, no degree

Graduate or professional degree (e.g., MA, MS, MBA, JD, MD, PhD)

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* 6. Sex

Female

Male

Non-binary

Prefer not to answer

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* 7. Are you a veteran of the U.S. Armed Forces?

Yes

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* 8. Employment Status:

Employed full-time

Employed part-time

Unemployed

Self-employed

Student

Other (please specify)

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* 9. What is your current hourly wage (if employed)?

$1-10

$11-$20

$21+

Not currently employed

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* 10. What is your total household income?

Less than $20,000

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $149,999

$150,000 or More

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* 11. Are you interested in training for any of the following positions? (Please only select one)

EKG Technician

Patient Care Technician

Medical Assistant

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* 12. Have you ever been convicted of a crime?

Yes

Other (please specify)