First Name

Last Name

Birth Day Year

Birth Day Month

Birth Day Day

Last four of Social Security Number

Address

Street

City

State

Zipcode

Phone Number (Example: 9199999999 No dashes please)

Emergency Contact Information

Contact Name

Contact phone number (Example 9192255698 No dashes please)

Education

High School Name

Grade completed

Did you graduate ? Yes No

Do you have your GED ? Yes No

Do you have any other Education ? Yes No

Did/do you attend college ? Yes No

If Yes, please list name, location, and number of years you attended

Did/do you attend vocational or trade school ? Yes No

If Yes, please list name, location, and number of years you attended

Any other education ?

Work History

Please provide information on your current or most recent job. (Note: Food service experience is not a
requirement for admission to the program.)

Are you currently employed ? Yes No

Please provide info about CURRENT OR MOST RECENT employment below.

Employer Name

Employer Full (street, city, state, zip) Address

Position

Supervisor Name(First and Last)

Dates of Employment Example: December 2005 to April 2006

Full Time Yes No

Part Time Yes No

Reason for Leaving

Do You receive any other type of financial assistance ? Yes No
If yes please explain

Approximately how much money did you earn last year ?

Have you ever been terminated from a job ? Yes No

If yes please explain

Considering your current job or last place of employment, answer the following questions:
What do/did you like best about work ?
What do/did you like least about work ?

Have you ever had a negative experience at work with a supervisor or co-worker ? Yes No
If yes explain the situation and outcome
If no how would you handle a negative experience with your co-worker or supervisor ?

What skills do you possess with regards to your past and present employment ?

Medical/Legal

In keeping with our mission, we ask that you disclose the following information.

Are you living in a transitional home, shelter, or any other social service program ?Yes No

If yes, what program

Are you involved with any type of drug or alcohol rehabilitation program ? Yes No

If yes, what program and what are the start and finish dates

Have you ever been convicted of a misdemeanor or felony ? Yes No

If yes, describe the charges and dates

Do you have any court cases pending ? Yes No

If yes, please describe

Name and Phone Number of caseworker/parole officer

Are you under a doctor's care ? Yes No
Name

Are you currently taking any prescription medicine or any other medication ? Yes No
If yes what

Do you experience any side effects such as drowsiness, dizzyness, impulsiveness, etc ?Yes No

Do you have any limitations with regard to working in a kitchenYes No

If yes, please describe

Are you allergic to latex (for example: latex food service gloves) ?Yes No

Do you have any food allergies ?Yes No

If Yes, what

What happens to you if you eat this food ?

Substance Abuse History

Do you currently use any type of drugs or alcohol ? Yes No

Have you in the past used any type of drugs or alcohol ? Yes No

What is your longest period abstaining from drugs or alcohol use ?

When was the last time you used drugs or alcohol ?

Are you currently involved in a self-help/support group ?Yes No

If yes, describe

Depression/Suicide

How do you deal with the feelings of helplessness or depression ?

Have you ever contemplated suicide ?Yes No Dates:

Did you just think about it or did you have a plan ?

If you had a plan what was your plan

Did you act upon it ?Yes No

Please explain

If you have had thoughts in the past, how do you feel now ?

Do you have some one you can discuss these feelings with ? Yes No

Who ?

Armed Forces

Are you a veteran of the Armed Forces ?Yes No

Yes, what branch, rank, and dates were in involved in ?

Type of dischargeHonorable Dishonarable Medical

Electronic Signature

We ask that you fill in the spaces below. This will count as your signature. If the application is not signed it will not be considered.

I verify with my signature that to the best of my knowledge all of the information above is correct and I
authorize the CJTP staff to confirm the information above (which may include contacting people mentioned in this application.