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LCC - Application Form (Dev)

"*" indicates required fields

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone #*

Email Address*

If accepted into the LCC program, can you provide proof of legal right to work in the U.S.?*

Yes

Your Age:*

18-19

20-21

22-23

24-26

If accepted into the LCC program, will you be able to provide the following?*

Check all that apply:

Social Security Card

Birth Certificate

California ID or Driver’s License

Proof of Household Income (i.e., Wiz report, check stub from yourself or someone in the household, SSI, etc.)

Have you ever participated in Fresno EOC Local Conservation Corps as a corpsmember?*

Yes

What program did you participate in?*

What dates were you in the program?*

Have you ever participated in YouthBuild Charter School of California?*

Yes

If accepted into the LCC what days are you available to work?*

Check all that apply:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What hours are you available to work on the days you selected?*

Check all that apply:

Morning

Afternoon

Evening

How did you hear about LCC?*

Check all that apply:

Social Media - Facebook, Instagram, Twitter, etc.

Internet Search (Google, Bing, Yahoo, etc.)

Friend/Family

Other

Other*

Please tell us how you heard about LCC here.

Do you have reliable transportation?*

Yes

Explain your transportation problem*

Education Status:*

Select one:

I have a GED

I have a High School Diploma

I have not completed HS Diploma or GED

What is the highest grade you completed?*

If you are accepted into the LCC program, you will be required to enroll in a formal education program (high school, college, career tech). Are you willing to do this?*

Yes

Are you currently enrolled in an educational school/program?*

Yes

Name of School/Program:*

Work History

List your current or most recent job first; include volunteer work history

Employer 1 Name

Employer 1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer 1 Phone

Dates you worked for this employer:

From Month, Day, Year to Month, Day Year

Job Title

Hourly Wage

Hours per Week

Reason for Leaving

Employer 2 Name

Employer 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer 2 Phone

Dates you worked for this employer:

From Month, Day, Year to Month, Day Year

Job Title

Hourly Wage

Hours per Week

Reason for Leaving

I need to add more employers

Employer 3 Name

Employer 3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer 3 Phone

Dates you worked for this employer:

From Month, Day, Year to Month, Day Year

Job Title

Hourly Wage

Hours per Week

Reason for Leaving

Employer 4 Name

Employer 4 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer 4 Phone

Dates you worked for this employer:

From Month, Day, Year to Month, Day Year

Job Title

Hourly Wage

Hours per Week

Reason for Leaving

Employer 5 Name

Employer 5 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer 5 Phone

Dates you worked for this employer:

From Month, Day, Year to Month, Day Year

Job Title

Hourly Wage

Hours per Week

Reason for Leaving

Why are you interested in joining the Fresno EOC Local Conservation Corps?*

References

List the names, addresses, and phone numbers of two persons, not relatives, who are familiar with your personal background, education, employment, and/or skills.

Reference 1 Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Occupation*

Relationship*

Reference 2 Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Occupation*

Relationship*

Declaration

I hereby certify that all statements made in this application are true and correct. I agree and understand that any misinformation or material omission could result in disqualification from the LCC Program. I understand that acceptance into the LCC program is contingent upon satisfactory completion of all pre-service requirements including, but not limited to interviews, non-paid orientation, reference checks, verification of legal right to work in U.S., and for certain positions, a criminal background check which will include an arrest record. Note: Conviction of an offence, including a felony, may not disqualify you for enrollment.

In the event that any or all of the above pre-service requirements are not met, I understand I will not be accepted into the LCC program.

I authorize organizations and persons named above to give information about me, and I release them from all liability.

Type Name Here

Signature

Signature (Test)*

Date of Signature*

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LCC - Application Form (Dev)

Work History

References

Declaration

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