Energy Pathways Program

ALL INFORMATION ENTERED WILL BE CONFIDENTIAL

Please fill out this application completely.

Do you have any experiences working with cars? If yes, please describe:
If interested in Automotive Technician Program, which program do you prefer:
GM (Start October 18, 2010) Chrysler (Start October 18, 2010) Import (Start March 14, 2011) Ford (Start January 10, 2011)

Gender Male Female
Highest level of education completed High School Diploma GED College Degree Not a High School Graduate
Citizenship Status: US Citizen US Permanent Resident N/A
Income Bracket: Less than $25,000 $26,000 - $30,000 $31,000 - $35,000 $36,000 - $40,000
Ethnicity (Optional): Hispanic White - Not Hispanic Black - Not Hispanic Filipino Asian Indian Cambodian Chinese Guamanian American Indian / Alaskan Native Others
How did you hear about the Energy Pathways Program? Please limit your response to under 500 characters.
Please answer the following questions:
Are you at least 18? Yes No
Do you have a valid drivers license? Yes No
Do you have a valid social security card? Yes No
Do you have any physical limitations that would impede you from working in a refinery? Yes No
Would you be willing to do a physical assessment? Yes No
Would you be willing to do a random drug test and/or alcohol screening? Yes No
Would you be willing to do a live-scan (background check) Yes No
Are you registered for selective service? Yes No

Have you participated in any free training programs within the last 3 years? Yes No
If “yes,” please state the programs you participated and whether you completed the program:

Do you have any workers compensation cases opened or closed? Yes No
If "yes," what year(s) were the case(s) and is it opened or closed? Please limit your response to under 500 characters.
Do you have any criminal history in the past 7 years (misdemeanors, felonies, and/or traffic convictions? Yes No
If "yes," please describe the year, the offense, and if you are currently on probation. Please limit your response to under 500 characters.
Do you have any misdemeanors or felonies? Yes No
If "yes," please describe the year, the offense, and if you are currently on probation. Please limit your response to under 500 characters.
Are you a Veteran? Yes No