Pre-Apprenticeship Construction Training Program Intake Form

First Name*

Last Name*

Other/Previous Name (which may appear on records)

Birthdate*

Social Security Number - Optional

Email*

Phone*

Mailing Address

Country*

Street*

City*

State*

Postal Code*

Have you ever taken a JCC class?

Census Information

Sex Assigned at Birth*

Gender Identity (Optional)

Country of Citizenship*

Race/Ethnicity*

Are you of Hispanic or Latino origin?

Yes

No

Military Affiliation*

If you would like to self-identify with a disability please mark the appropriate category(ies). Someone from the Accommodative Services Office will reach out to connect with you about available services.*

Are you unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment?

Yes

No

School Information

Admissions into this course does not require the applicant to have a high school diploma or GED. However, many of the national exams do require the examinee to have a high school diploma or GED in order to sit for the certification.

Education Data*

This is a grant funded program for qualified individuals. Eligible individuals must meet New York State Department of Labor (NYSDOL) Dislocated Worker definition. There are six categories of Dislocated Worker. Simplified, to qualify as a Dislocated Worker, you must be “underemployed” or “unemployed”. Underemployed means that you are working at a wage that is below your skill level or less then your previous job. Unemployed means you are not working currently. To determine your eligibility, complete the following questionnaire which covers all six eligible categories.

If you have questions on the eligibility criteria please call The WorkPlace for assistance at 315-786-3659.

Category 1 – Unlikely to Return to a Previous Occupation/Industry

Have you been terminated or laid off, or received a notice of termination or layoff, from employment, including separation from active military service (under other than dishonorable conditions)

Yes

No

Are you unlikely to return to a previous industry or occupation (select all that apply)

Are you attached to the workforce in any of these ways?

Category 2 – Mass Layoff or Closure

Were you employed at a business that closed or experienced a substantial layoff:

Are you employed at a facility at which the employer has made a general announcement that such facility will close within 180 days

Yes

No

Are you employed at a facility at which the employer has made a general announcement that such facility or military installation will close (no firm date or date not within 180 days)

Yes

No

Category 3 – Self-Employed

Were you self-employed but are now unemployed because of general economic conditions in the community in which you reside or because of natural disasters

Yes

No

Category 4 – DW Displaced Homemaker

Have you been providing unpaid services (any service provided without an employer/employee relationship) to family members in the home

Yes

No

Unemployed/Underemployed

I am unemployed & having trouble in obtaining or upgrading employment

I am underemployed & having trouble in obtaining or upgrading employment

N/A

Attachment to the workforce

Are you eligible for or have you exhausted UI benefits?

Have you worked for two full pay periods or one month, whichever is less?

N/A

Category 5 – Dislocated Due to Foreign Trade

Were you dislocated due to foreign trade, including participants in the Trade Adjustment Assistance (TAA) Program who are part of a worker group covered under a certified trade petition, which demonstrates an increase in imports, a shift or acquisition in production, or a loss of sales and/or production which contributed importantly to the worker’s separation or threat of separation.

Yes

No

Category 6 – Spouse of a Member of the Armed Forces

Are you the spouse of a member of the Armed Forces on active duty & who has experienced a loss of employment as a direct result of relocation to accommodate a permanent change in duty station of such member?

Yes

No

Are you the spouse of a member of the Armed Forces on active duty who is unemployed or underemployed and is having trouble in obtaining or upgrading employment?

Yes

No