HVAC/R Application YCC HVAC/R Application First Name * Last Name * Phone Number * Email Address * Home Address * What type of housing situation best applies to you? * Public Housing Own a Home Renting Shelter Homeless Race / Ethnicity * Black / African American Hispanic / Latino White / Caucasian Native American Other Sex * Your Age * 17 18 19 20 21 22 23 24 Birth Month * 01-Jan 02-Feb 03-Mar 04-Apr 05-May 06-Jun 07-Jul 08-Aug 09-Sep 10-Oct 11-Nov 12-Dec Birth Day * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year * 2002 2001 2000 1999 1998 1997 1996 1995 Do you have a valid social security number (SSN) * Yes No Do you have a valid form of official photo identification? * Yes No This includes a Driver's license or a state ID. Do you currently receive any government assistance? If yes, what kind? (SNAP, housing, etc) * Have you completed high school? * Yes No No, but some GED No, but earned GED Are you on probation? * Yes No Are you on parole? * Yes No Have you held a job before? * Yes, I am working now. Yes, but I am not working now. No. If you are working now, please describe your current job. * Do you have any health conditions that we should know about? (Ex. diabetes, asthma, allergies, pregnancy) * reCAPTCHA Submit Δ
