Please answer all questions as accurately as possible.

PERSONAL INFORMATION

1. First Name*

2. Last Name*

3. Middle Initial

4. Date of Birth*

5. Gender*

Select One Male Female Prefer Not to Say

6. Street Address*

7. Apt. #*

8. City*

9. State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

10. Zip Code*

11. Phone*

12. Alternate Phone*

13. Email Address*

14. Ethnicity*

Select One Hispanic Non-Hispanics

15. Race (check all that apply):*

American Indian or Alaskan Native Asian Black or African American

Native Hawaiian or other Pacific Islander White

16. Are you a U.S. Citizen?*

Yes

No

17. If not, are you authorized to work in the U.S.?*

Yes

No

18. Do you have a Driver's License?*

Yes

No

19. If so, what type of Driver's License?*

EDUCATION

20. High School (please check one):*

No Diploma High School Diploma

GED

21. College (please check one):*

Some College Bachelor's Degree

Master's Degree

INCOME

22. Are you currently employed?*

Yes

No

23. Sources of Income (check all that may apply):*

Wages Social Security Public Assistance

Unemployment Other

24. How many weeks were you out of in the last 26 weeks?*

CERTIFICATES/LICENSES

25. Do you have any vocational, technical, academic certificates, or licenses?*

Yes

No

26. If so, please list:*

27. Name of the organization that issued certificate/license:

28. Date Issued:

29. Are you currently enrolled in a training program?*

Yes

No

30. If yes, what is the name of the training program?*

31. Date Started*

32. Expected End Date:*

SKILLS

33. Please check all that apply*

Boilermaker Carpenter Concrete Drywall Electrician Elevator Equipment Operator HVAC Insulator Iron Worker Laborer

Landscaping Lead/Asbestos/Abatement Painting Paving Plastering Plumbing Roofing Sheet Metal Site Work Excavation Truck Driver

34. Other (List):

PLEASE READ AND SIGN

I declare under penalty of perjury, under the laws of the State of New York, that the information contained in this application and any accompanying documents are true and correct, with full knowledge that all statements made in this application are subject to investigation and that any false or dishonest answer to any question may be grounds for immediate termination.

In addition, I have been informed that a supervised drug test will be required during the Job Readiness Training
(JRT) workshop. Failure to take the test and/or failure of that test will be cause for removal from any and all employment and/or training opportunities that are funded through the Buffalo Municipal Housing Authority. At the discretion of the Buffalo Municipal Housing Authority, I may be subject to a random drug test if more than 26 weeks have elapsed from the time of the first drug test and my employment on a BMHA construction project.

Finally, 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.

“BMHA is an Equal Opportunity/Affirmative Action Employer”

E-Signature*

Date*

DETERMINING ELIGIBILITY

Please click on the link below for determining eligibility (PDF). Please bring at least one type of documentation from each category about your household situation. Section 3 certification is valid for 3 years from the date of certification.

CLICK HERE TO DETERMINE ELIGIBILITY