APPRENTICE AND STUDENT

APPLICATION

Associated Builders and Contractors

of Southeastern Michigan

31800 Sherman Ave

Madison Heights, MI 48071

Phone: (248) 298-3600 Fax: (248) 298-3606

 

Office Use Only:

 

Student Code #

 

Employer I.D. # 38-2400995

 

 

PLEASE PRINT CLEARLY:

 Today's Date:______________________

Name: (Last, First, MI)____________________________________________ Social Security # ______________________

Address: _________________________________________________________________________________________

City:______________________________________________________________ State:____________ Zip:__________

Home Phone: (____)_____-__________                       To Notify you of class changes, etc. (____)_____-__________

 

 

Associated Builders and Contractors of Southeastern Michigan, Inc. does not discriminate on the basis of sex, race, color, national and ethnic origin in administration of it's education policies, admissions policies, scholarship and loan programs, and other school administered programs.

 

Have you applied for this program before? (yes/no)__________ If "yes", what year?__________

 

How did you hear about this program?
  (  ) ABC Member Employer (  ) Non-member employer (  ) School Placement Program
  (  ) MESC Office (  ) Urban League (  ) Women's Resource Center
  (  ) Newspaper (  ) Brochure / Catalog (  ) Personal Contact

 

(  ) ABC Student Referral (Print Name) _________________

(  ) Other (Explain)___________

 

Trade You Are Enrolling For: (Check One)
  (  ) Carpentry (  ) Electrical (  ) Plumbing
  (  ) Heating, Ventilation & Air Conditioning (HVAC) (  ) Sheet Metal
  (  ) Drywall (  ) Masonry (  ) Sprinkle Fitter
  (  ) Roofing (  ) Glazing (  ) Painting

 

(  ) Other __________________________________________________________________

 

 

Office Use Only:

Check if T.A.

 

 

 

 

 

 

 

Education:
Are you a High School Graduate? (yes/no)_____________ Do you have a G.E.D.? (yes/no)______________________
If you answered "NO" to the above questions, the highest grade completed.___________________________________
Last High School Attended:__________________________________________________________________________

Address: (if known)________________________ City: ___________________________ State:____ ZIP:___________

 

 

 

Construction Related Education (other than high school)
Name of Training Facility: _________________________________ Counselor's Name:__________________________
Address: _______________________________ City: ___________________________ State:____ Zip: ____________
Years Attended From:__________ To: __________ Received Certificate / Diploma? (yes/no)  ____________________
Classes Taken: ___________________________________________________________________________________

Skills Learned: ____________________________________________________________________________________

 

 

 

Personal / Medical Information
Are you currently taking any medication? (yes/no) ______ If yes, list each medication and illness being treated below.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Physician's Name: __________________________________________ Phone Number: _________________________

 

 

 

In Case Of Emergency:
Name of person to notify: (last, first) _____________________________ Relationship to you: ____________________
Address: _______________________________ City: ___________________________ State:____ Zip: ____________
Phone: (_____)_____-_________
 
I Understand that any false or misleading information furnished by me on this application form or in connection with my application for apprenticeship may result in rejection of the application, or if employed, termination of employment. I also understand that this is not an application for employment and does not guarantee me placement into the apprenticeship program. By signing this application, I give permission to contact any of the employers or persons listed herein.
 

Your Signature:_________________________________ Today's Date: ____________________________

 

 

 

Construction Related Employment (List present employer first)
Company Name: __________________________________________________________________________________
Supervisors Name: ________________________________________________________________________________
Address: _______________________________ City: ___________________________ State:____ Zip: ____________
Dates Employed From: _______________ To: _______________ Pay Rate $ _________________________________
Job Description: ___________________________________________________________________________________
_________________________________________________________________________________________________
Reason For Leaving: _______________________________________________________________________________

_________________________________________________________________________________________________

 

 

Company Name: __________________________________________________________________________________
Supervisors Name: ________________________________________________________________________________
Address: _______________________________ City: ___________________________ State:____ Zip: ____________
Dates Employed From: _______________ To: _______________ Pay Rate $ _________________________________
Job Description: ___________________________________________________________________________________
_________________________________________________________________________________________________
Reason For Leaving: _______________________________________________________________________________

_________________________________________________________________________________________________

 

 

PRIVACY ACT STATEMENT

The following voluntary information is required for use in apprenticeship statistical reporting, as requested by the Department of Labor, Bureau of Apprenticeship and Training, and may not be otherwise disclosed without the express permission of the person listed below.

(Privacy Act of 1974 - P.L. 93-579)

 
PLEASE PRINT      Name: (Last, First, Middle) _________________________________________________________
Race / Ethnic Group: (   ) Caucasian (   ) African American (   ) Hispanic
  (   ) Asian / Pacific Island (   ) Vietnamese (   ) American Indian
  (   ) Veteran (   ) Non-Veteran  

If you checked "Veteran" List years enlisted: From: ____________________ To: ____________________
Birth Date: (Month, Day, Year) _______________________________________________ Sex: (   ) Male / (   ) Female