Delaware Skills Center Admissions Application

Admissions Application
Course of Interest*
Gender*

MaleFemale
Applicant Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number:*

Area CodePhone Number
Home Phone Number:*

Area CodePhone Number
E-mail*
Are you a United States citizen?*

YesNo
Are you registered for Selective Service? (Males Only)*

YesNo
If not, click on the following link to register: https://www.sss.gov/Registration/Register-Now/Registration-Form
Personal Information
Is English your second language?*

YesNo
Preferred Language:*
Do you have a valid State of Delaware driver's license?*

YesNo
Is your license subject to revocation or suspension within the next 4 months?*

YesNo
Do you have your own vehicle for transportation?*

YesNo
Veteran Status
Veteran:*

YesNo
Education
Are you a High School Graduate?*

YesNo
Highest Grade Completed*
What is the name of the High School or GED program attended?*
Graduation Date*

MonthDayYear
Date
Name of Post-Secondary Institution and Major
Please add dates of enrollment
Have you attended other training programs in the last 5 years?*

YesNo
If Yes, list the school and course name.
Have you ever attended a training programs at the Delaware Skills Center?*

YesNo
If Yes, list course name:
Physical Data
General Health (check one):

ExcellentGoodFairPoor
Do you have any physical limitations that would prevent you from completing this training program?*

YesNo
If you selected yes please explain:
Can you lift over 40 pounds?*

YesNo
Background*

Does not exclude you from program.
Have you ever been convicted of a criminal offense?*

YesNo
If yes, give date and brief explanation:
Have you ever been on probation?*

YesNo
Are you currently on probation?*

YesNo
If Yes, who is your Probation/Parole Officer and what is their phone number?
Do you have any court appearances within the next 4 months?*

YesNo
If yes, give date(s) and explain:
Work Experience (if applicable)
Are you currently employed?*

YesNo
Name of Employer:*
Job Title:*
What is your Salary or Hourly Wage? *
Start Date (of current job):*

MonthDayYear
End Date:

MonthDayYear
Employer’s Name and Phone Number:*
Job Duties & Responsibilities:
Are you presently collecting workers’ compensation or disability pay?*

YesNo
Are you presently collecting unemployment?

YesNo
Upload Resume (Optional)

Upload a File

Cancelof
_________________________________________________________________
Is there anything that would prevent you from accepting full time permanent employment upon completion of this course and maintaining your employment for a minimum of 90 days?*

YesNo
If yes please explain in detail
How did you learn about the Delaware Skills Center?*
Name of Referrer:

First NameLast Name
The ultimate goal and mission of the Delaware Skills Center is full-time employment upon completion of training. I understand that in order to become gainfully employed, I must be free of illegal chemical substances and willing to submit to "drug screening" by perspective employers prior to being hired. If I am found to be using or abusing illegal chemical substances, I will be unable to participate in "placement activities" and therefore not eligible for enrollment at The Delaware Skills Center
All of the information I have provided is true to the best of my knowledge and I fully understand that I will be immediately disqualified from training if the information is false or misrepresented.*

YesNo
Applicants Full Name*
Date

MonthDayYear
Should be Empty:

Admissions Application

Personal Information

Veteran Status

Education

Physical Data

Background*

Work Experience (if applicable)