Demographic Information

Current Employment Status*

Unemployed
Dislocated Worker
Part-Time / Contract Employment
Full-Time Employment

How long (in months) have you been out of unemployed or a dislocated worker?

Reason(s) for education*

Check all that may apply.

Unemployed / dislocated and looking to re-join the workforce
Looking to change careers
Looking to update skills at current career
Other (please explain)

Other (reasons for training)

Please explain reason(s) for training

Current or most recent Job Title*

Gender*

Male
Female
Prefer not to answer

Age*

Ethnicity*

Marital Status*

Single
Married
Divorced
Widowed
Prefer not to answer

Highest Level of Education*

Are you currently enrolled in any post-secondary school?*

Yes
No

If yes, what is your current School Name?

Are you a US Veteran?*

Yes
No

Veterans - Have you or are you currently using education benefits through GI Bill, Post 09/11 Bill or related?

Yes
No

Have you ever received educational funding from or worked with any of the following organizations?*

None
Workforce Center
Vocational Rehabilitation
Other (please explain)

Please describe the organizations name and location from which you have received educational funding.

Are you currently enrolled in a DWC payment plan?*

Yes
No

What Industry did you most recently work in?

Please check all that apply:

Most Recent Annual Income*

Please enter an estimate of your last known annual salary. This metric will help us to understand how our training will help you increase your wages in the future.

Under $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 - $75,000
$75,000 - $100,000
$100,000 - $150,000
$150,000 or more
Prefer Not to Answer

What is your current estimated monthly income?*

Has your income been impacted by the Covid-19 pandemic?*

Yes
No

If yes, please describe how your income has been impacted, including how much were earning (monthly average) before and after the pandemic.

How did you hear about us?*

Online search/Google
HR Department
Local Organization
Personal recommendation
Social Media
Other

Networking Group,Chamber of Commerce or Association Name

Other

Please fill-in how you heard about us.

Tech Skills Scholarship

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