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Section 3 Resident Application

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