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IAMBK Green Certification course
Personal Profile
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Indicates required field
Name (Last, First Middle)
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Are you a United States citizen, national, or lawful permanent resident?
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Yes
No
Social Security Number
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Gender
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Male
Female
Date of Birth
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Place of Birth (City/State?Country)
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Do you have a VALID Driver’s License?
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Yes
No
Driver's License Number
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Do You Have a personal vehicle?
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Yes
No
Current contact information –
correspondence will be sent to indicated address unless you notify us of a change
Number and street name (if possible, include a street address when using a P.O. Box)
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City
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Home Phone
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State
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Work Phone
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Zip
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Cell Phone
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Email
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Please notify us promptly of any change in the above information.
Alternate Contact –
please provide the name and address of someone through whom you can always be reached.
Name Relationship
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Number and street name (if possible, include a street address when using a P.O. Box)
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City
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State
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Zip
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Home Phone
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Work Phone
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Race/ethnicity: (check all that apply)
Choose Any
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American Indian/Alaskan Native
Black/African-American
Black/African-American & White
American Indian/Alaskan Native & White
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & Black/African-American
Asian
Asian & White
Other Multi Racial
Choose One
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Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race
Not Hispanic or Latino: A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race
Education
Select next to the highest level of education that you will have completed by the time you are planning on participating in this program.
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Some high school Associate’s degree Graduate degree
High school diploma/GED some college
Technical school/apprenticeship Bachelor’s degree
Other (Specify Below)
Other
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List all schools including high school that you have attended, including trade or technical schools, military training, and employment training programs. Start with the most recent. You may attach another sheet if you wish to include more entries or information.
Name of school or institution
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Dates attended
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Type of degree
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Major or area of study
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Date received
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Name of school or institution
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Dates attended
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Major or area of study
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Type of degree
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Date received
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Employment
List the last three positions you have held. Please, BEGIN WITH THE CURRENT or most recent and GO BACK AS FAR AS NECESSARY. Include self-employment, internships/fellowships, home management, and full- or part-time paid or unpaid work experience. You may attach another sheet if you wish to include more entries or information.
Organization Name
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Organization Address
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Supervisor Name
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Supervisor Phone Number
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Date employment began
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Hours per week
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Date employment ended
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Job title
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Duties
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Rate of Pay
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Reason for Leaving
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Organization Name
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Organization addres
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Supervisor Name
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Supervisor Phone Number
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Date employment began
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Hours per week
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Date employment ended
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Job Title
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Duties
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Rate of pay
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Reason for leaving
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Income
Household size
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1
2
3
4
5
6
7
8
Annual Income
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References
Please provide the names and contact information of two people (not related to you) who know you well and can supply accurate personal or professional references. Include at least one
Professional Reference
Name
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Business Name (If Applicable)
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Phone Number
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Name
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Business Name (If Applicable)
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Phone Number
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Relationship
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Email
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How long have you known this person?
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Relationship
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Email
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How long have you known this person?
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IMPORTANT – Please read carefully!
Existence of a criminal background will not necessarily disqualify you from consideration. However, misrepresentation of that record (lying, not telling the whole truth) will disqualify you immediately. A background check will be pursued for all applicants.
Have you ever been charged, as a juvenile or adult offender, with any criminal offense? Please list all charges, regardless of outcome.
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NO
YES
If ‘yes,’ please explain below
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Felony
Misdemeanor
Date
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Charge
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Location
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Outcome
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Are you now under charges for any offenses or are any civil suits or judgments pending against you? (Do not include minor traffic violations)
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NO
YES
If ‘yes,’ please explain the current status of your case, and list the name and contact information of your lawyer or public defender.
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Are you now on probation or parole?
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NO
YES
If ‘yes,’ please specify which”
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Please provide the name, address, and phone number of the court, probation, or parole officer who we can contact to verify the above information:
Name
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Title
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Address
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Phone Number
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Email
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Please contact this person before submitting the application and let him/her know that we will be in contact and are authorized to receive information.
Drug Screening Policy
Please read carefully and sign below ONLY if you answer ‘YES’ to the question. Applications without signatures will NOT be considered. IAMBK Green is a Private funded non-profit training program committed to a drug-free work force. All prospective applicants will be screened for use of illicit drugs before acceptance into the IAMBK Green. The employers who will be interviewing graduates of the IAMBK Green program have agreed to do so based on our strict drug-free policy, and will require any prospective employees to submit to an additional drug screening.
Are you willing to submit to drug screenings at any point during your IAMBK Green Environmental Literacy Certification Workforce Development Training Program as a requirement for acceptance and continued enrollment in the program?
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YES
NO
Signature (Enter Name)
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Date
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Submit
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IAMBK Food Distribution
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Meet The Team
Programs
COVID-19 UPDATES
