LEADS Workforce Development Application

LEADS Application

Leadership, Education, Action, Development, and Sustainability

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Social Security Number

Date of Birth

Race

Gender

What is your current income range?

$10,000-$20,000
$21,000-$30,000
$31,000-$40,000
$41,000-$50,000

Are you a veteran?

Yes
No

Are you a person with a disability?

Yes
No

Do you have a valid driver's license?

Yes
No

Education

What is your highest level of education?

High School:

High School Address:

Street Address Address Line 2 City State ZIP Code

What years were you in high school?

e.g, 2004-2008

Did you graduate?

Yes
No

Diploma:

GED:

GED Institution Address:

Street Address Address Line 2 City State ZIP Code

What years did you work toward your GRE?

e.g, 2004-2008

Did you graduate?

Yes
No

Diploma:

Employment

Are you currently employed?

Yes
No

How long have you been unemployed (if applicable)?

Company or last company you worked for:

Phone

Address

Street Address Address Line 2 City State ZIP Code

Your Job Title:

Responsibilities:

Employment Period:

e.g., employed from December 2017 to March 2019

Supervisor:

Reason for Leaving:

Are you willing to complete and 8-week financial literacy course?

Yes
No

Do you have access to a computer/tablet to log in to a virtual financial literacy course?

Yes
No

Do you have access to internet services?

Yes
No

How did you hear about this workforce program?

Newspaper
DHA employee
Social media
Other

If other, please explain:

Have you ever been arrested or awaiting charges for trial or sentencing?

Yes
No
Decline to answer

Would you like to be contacted by our RISE UP grant, which offers free expungement clinics?

Yes
No
I would like additional information

Program Interest

What programs are you interested in? Choose from one of the following drop down menus.

MDCC-CAPPS Center

Hinds CC-Vicksburg Campus

MDCC – Career & Technical Center

Holmes Community College

S&S College of Hair

References

Please list two references (no family members).

Name

First Last

Relationship:

Company/organization:

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Relationship:

Company/organization:

Phone

Address

Street Address Address Line 2 City State ZIP Code

Applicant Name:

First Last

Applicant Signature:*

Date*

LEADS Workforce Development Application

LEADS Application

LEADS Application

Education

Employment

Program Interest

References

Get Involved: