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2. Date
   Date
4. First Name
5. Middle Initial
6. Last Name
8. Date of Birth
   Date of Birth
9. Gender

   1. Female
   2. Male
10. AMP
    BMHA Resident Only
12. Address
14. City
15. State
16. Zip Code
18. Phone Number
19. Alternate Telephone
21. Email Address
23. Ethnicity

    1. Hispanic
    2. Non-Hispanic
24. Race

    1. African American
    2. American Indian/Alaska Native
    3. Asian

    1. Pacific Islander
    2. White
26. Are you a U.S. Citizen?

    1. Yes
    2. No
27. If no, are you authorized to work in the U.S.?

    1. Yes
    2. No
29. Do you have a Driver’s License?

    1. Yes
    2. No
30. Type of License
32. Do you have access to a vehicle?

    1. Yes
    2. No
34. Are you presently employed?

    1. Yes
    2. No
36. Do you have any vocational, technical, academic certificates or licenses?

    1. Yes
    2. No

    If you are applying for a construction position, OSHA safety training is mandatory.
37. Please list all vocational, technical, academic certificates or licenses
39. Check up to 3 areas that you have experience in

    1. Abatement
    2. Boilermaker
    3. Bricklayer
    4. Carpenter
    5. Cement
    6. Electrician
    7. Elevator Constructor
    8. Equipment Operator

    1. HVAC
    2. Insulator
    3. Iron Worker
    4. Laborer
    5. Landscaping
    6. Lead/Asbestos
    7. Painter

    1. Paving
    2. Plasterer
    3. Plumber
    4. Roofer
    5. Sheet Metal
    6. Site Work Excavation
    7. Truck Driver
41. I attest that the information stated above is true and accurate, and understand that the information, if misrepresented or incomplete, may be grounds for immediate termination.
    
    In addition, I have been informed that the information provided will be discreetly managed and will be used for the administration of this program. To that end, your name, address and information concerning your training and qualifications may be disclosed to prospective employers and/or training providers. Your signature below authorizes such disclosure.
43. E-Signature*
44. Date
    Date
46. Contact Linda Gleason at 716-855-7580, ext. 304 to schedule an appointment for eligibility determination.
    Contact David Granville at 716-855-7580, ext. 305 to schedule the 10 hour OSHA General Construction class.
48. View the Documentation Used for Determining Eligibility (PDF). Please bring at least one type of documentation from each category pertaining to your household situation. Section 3 certification is valid for 3 years from the date of certification.
50. Section 3 Resident Certification Documentation Verified
52. Eligible Age (18 plus years old)

    1. Yes
    2. No
53. Residency

    1. Yes
    2. No
55. Income
    Total Family Gross Income
56. Social Security Card

    1. Yes
    2. No
58. 10 hour OSHA Certified

    1. Yes
    2. No
59. Date Completed
    Date Completed
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field