Arizona Career Pathways Application

Last Name-----------------------------
First Name-----------------------------
Middle Name---------------------------
Maiden Name----------------------------
Suffix _____ Jr. _____ Sr. _____ III _____ IV
Date of Birth---------------------------
Gender ______ Male ______ Female
Please check which racial / ethnic category best describes you.
Race
__ Amer Indian / Alaskan Native __ Black / African American
__ American Indian / Alaskan Native & White __ Black / African American & White

__ Amer Indian / Alaskan Native / Black & African Amer __ Hawaiian / Other Pacific Islander

__ Asian __ Other Multi - Racial

__ Asian / White __ White
Ethnicity ____ Hispanic or _____ Latino
Citizenship ___ US Citizen ___ Permanent Resident I-155 ___ Refugee ___ Other
Visa Expiration
Visa Number
Date:
Marital Status ___ Married ___ Single, Divorced or Separated ___ Widow

Household Information
Living Arrangement ___ Living with Relatives ___Living with Friends ___ Shelter ___ Living on Own ___ Other
Are you head of household? _____ YES _____ NO
# in household including yourself
Spouse's Name
Do you have children? _____ YES _____ NO
# of dependent children UNDER the
age of 18
# of dependent children OVER the age
of 18 (please explain)
Current Address Information & Contact Information
Current Address
Current City, State, Zip
Do you live within the City limits? _____ YES _____ NO _____ Don't know
Current County ___ Less than 1 year ___ At least 1 year
Home Phone Number Work Phone Number
Cell Phone Number
Email Address

P.O. Box or Preferred Mailing Address Information (if different than above)
Preferred Mailing Address
Preferred Mailing City, State, Zip

Education Information
Educational Status ___HS Graduate ___GED
High School Name
High School City, State & Country
High School / GED Graduation Date

College / University / Trade School Information

Circle any post-high school education you have completed or you are currently enrolled and give details below
Community College University Training Program
Name, City, State, Country
Dates Attended
If degree earned, please specify: _____ Associates _____ Bachelors _____ Masters
Degree Earned
Degree Graduation date
College Graduation Date College ID if currently enrolled
Additional educational experience
Military Information
Below: Check as many items as necessary to explain your background. Answers to these questions can not disqualify you from the program
and may help you qualify.
Have you served in the Armed Forces? _____ YES _____ NO _____ Currently Serving
If served in Armed Forces, indicate branch
Type of discharge?
Are you registered with Selective Service? (males ages 18 - 24) _____ YES _____ NO
Criminal Background
Have you ever been convicted of a felony? ________ YES ________ NO
Have you ever been convicted of a misdemeanor? ________ YES ________ NO
If yes, list charge and date
Other than minor traffic violations
Public Assistance
Check any assistance that you are receiving now and enter amounts.
_____AHCCCS _____TANF (AFDC) $
_____Child care assistance $ _____ Utilities assistance $
_____Food stamps $ _____WIC
_____Free or reduced lunch $
_____KIDSCARE
_____Public Housing $
_____ Refugee Assistance $
From Date To date
Are you currently on SSI (Disability)? _____ YES _____ NO / /
From Date To date
Are you currently unemployed? _____ YES _____ NO / /
From Date To date
Are you currently receiving unemployment benefits? _____ YES _____ NO / /
From Date To date
Are you currently receiving Workman's Compensation? _____ YES _____ NO / /
From Date To date
Are you currently in a Vocational Rehab Program? _____ YES _____ NO / /
Work Experience - ______Employed _____Unemployed
If Employed, please complete the following:
Employer
Address
Phone number Hours per Week
Occupation:
Start Date End Date
Starting Wage per hour $ Ending Wage per Hour $
Does this employer offer any benefits: Y / N If so, what benefits: Circle all that apply below.
Vacation Sick Days PTO Dental Health Ins. Retirement Pension Plan
If you hold a Second Job, please complete the following:
Employer
Address
Phone number Hours per Week
Occupation:
Start Date End Date
Starting Wage per hour $ Ending Wage per Hour $
Does this employer offer any benefits: Y / N If so, what benefits: Circle all that apply below.
Vacation Sick Days PTO Dental Health Ins Retirement Pension Plan
Spouse's Current Employer Information
_______UNEMPLOYED ________EMPLOYED If employed, please complete employer information below
Employer
Address
Phone number Hours per Week
Occupation:
Start Date End Date
Starting Wage per hour $ Ending Wage per Hour $
Does this employer offer any benefits: Y / N If so, what benefits: Circle all that apply below.
Vacation Sick Days PTO Dental Health Ins. Retirement Pension Plan
I attest that the information listed above is true and correct to the best of my knowledge.

_____________________________________________ _______________________________________________________
Signature Date Arzona Career Pathways Counselor Date
5.16.2011