Wallace State Community College
Workforce Training Solutions
256.352.7811
workforce@wallacestate.edu

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* Application Date:

Date / Time

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* PARTICIPANT INFORMATION

Full Name (Please DO NOT use all capital letters nor answer with N/A):

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* 4 Digit Date of Birth (Ex. Jan 22=0122)

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* Social Security Number (please enter in ###-##-#### format):

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* Mailing Address (Please DO NOT use all capital letters
nor answer with N/A):

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* Phone Numbers (Please include Area Code in this format: ###-###-####):

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* Email Address:

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* Group Number

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* DEMOGRAPHIC INFORMATION

U.S. Citizen:

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* Gender:

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* Age Range:

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* Race:

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* Primary Laguage

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* Are you registered for the draft? 

MALES BORN AFTER 1960 MUST REGISTER

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* Are you a Veteran?

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* Do you acknowledge a disability?

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* EDUCATION BACKGROUND

Highest Level of Education at Enrollment:

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* Have you previously earned the National Career Readiness Certificate?

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* EMPLOYMENT BACKGROUND

Employment Status at Enrollment:

Employed:

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* Employer's Name:

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* Employer's Address:

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* Length of employment:

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* Emergency Contact Information

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