HomeMy Public PortalAbout2019 ERTC Scholarship ApplicationENVIRONMENTAL RESOURCES TRAINING CENTER
Application for Admission
One -Year
Water Quality Control Operations Program
Social Security Number
Date of Birth (mo/day/yr): / /
❑ Male ❑ Female ❑I'd rather not answer
Applying for term beginning in Fall 20
LegalName
Permanent Home Address County
City or Town State ZIP
Telephone ( )
Mailing Address (If different than permanent)
City or Town State ZIP
Telephone ( )
Are you a veteran? UYes ❑No
Are you disabled? ❑Yes ❑No
Are you aU. S. Citizen? OEYes CINo
If no, state your Alien Registration Number
Permanent Residents must provide a copy of their Alien Registration Card (Green Card) for review.
Have you been affected by TAA? ❑Yes ❑No
Ethnic Origin:
Do you consider yourself Hispanic or Latino? ❑Yes ❑No
Do you consider yourself American Indian or Alaska Native? ❑Yes ❑No
Do you consider yourself Asian? ❑Yes ❑No
Do you consider yourself White? ❑Yes ❑No
Do you consider yourself Black/African American? ❑Yes ❑No
Do you consider yourself Native Hawaiian/Pacific Islander? ❑Yes UNo
Highest Level of Education Attained (please circle one)
Less than a High School Diploma
High School Diploma
GED
Some College
Associates Degree
Bachelor's Degree of Higher
CERTIFICATION:
I certify that the statements I have made on this application are correct and complete.
Signature Date
March 2016