Application For Employment Form Page 2
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1
2EDUCATION STATUS
CURRENTLY ATTENDING SCHOOL?
YES
NO
PROGRAM/MAJOR:
LAST GRADE COMPLETED:
0-11 (Please specify last grade completed):
HIGH SCHOOL DIPLOMA
GED
CERTIFICATION
1 YEAR DIPLOMA
ASSOCIATE’S DEGREE
BACHELOR’S DEGREE
MASTER’S DEGREE
DOCTORATE
I BELIEVE I LACK THE CAREER AND TECHNICAL SKILLS NEEDED TO OBTAIN A JOB THAT
YES
NO
PROVIDES FOR MY FAMILY’S BASIC
NEEDS.
TRAINING/SERVICES/ASSISTANCE NEEDED
ARE YOUR CURRENTLY ENROLLED IN ONE OR MORE OF THE FOLLOWING PROGRAMS? PLEASE CHECK ALL THAT
APPLY?
ADULT BASIC EDUCATION/ GED/ ENGLISH AS A SECOND LANGUAGE
GAP
KPACE- KIRKWOOD PATHWAYS FOR ACADEMIC CAREER EDUCATION AND EMPLOYMENT
PROJECT START/FINISH
KIRKWOOD COMMUNITY COLLEGE
OTHER (Please Specify):
PLEASE SPECIFY THE INDUSTRY YOU DESIRE TO WORK IN:
ADVANCED MANUFACTURING
OTHER (Please Specify):
HEALTHCARE
UNKNOWN
INFORMATION TECHNOLOGY
DISCLOSURE/RELEASE OF INFORMATION/SIGNATURE
Please check this box to verify you have read and agree to the following statement. Then print the form to
provide your social security number, signature and date.
I provide permission to Kirkwood Community College to release personally identifiable information from my
education records to assist the Iowa Department of education in obtaining and reporting information concerning
the placement and retention of students in employment as required by section 212 of the Adult Education and
Family Literacy Act. I understand that the personally identifiable information will be disclosed by Kirkwood
Community College to Iowa Workforce Development and the National Student Clearinghouse. This information
may not be re-disclosed to others and will be destroyed as soon as all statistical analysis has been performed, or
when the information is no longer needed, whichever date comes first.
Social Security Number:________________________
Signature: ______________________________________
Parent Signature (if under the age of 18): _____________________________________
Date: __________________________________
Thank you for completing this initial application. A Kirkwood team member will be in contact with you to further
discuss the information you have provided and assist you with connecting to services to address your interests
and/or needs.
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