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APPRENTICE APPLICATION MECHATRONICS TECHNICIAN (Chippewa Valley Technical College)

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Department of Workforce Development
Bureau of Apprenticeship Standards
APPRENTICE APPLICATION – MECHATRONICS TECHNICIAN
The information requested on this form is required under Wis. Stat. § 106.01(1) and Wis. Admin. Code § DWD 295.07 and is necessary to enter into a
registered apprentice contract in the state of Wisconsin. Personal information you provide may be used for secondary purposes [Privacy Law, s.
15.04(1)(m), Wis. Stats]. Provision of your social security number (SSN) is required and failure to provide it will result in the disqualification of your
apprenticeship application.
Prospective Sponsoring Employer
Social Security Number
Application Date
Name (First) (Middle) (Last)
Street Address or P.O. Box
City
State
Zip Code
Telephone Number
( )
Cell Phone Number
( )
E-Mail Address
Birth Date
EDUCATION LEVEL
8th grade or less 9th to 12th Grade GED or HSED
High School Graduate or greater Post-Secondary or Technical Training
CAREER HISTORY (complete all that apply)
WI Youth Apprenticeship: Yes No
School District/Consortia:
Certified Pre-apprenticeship: Yes No
Name of Certified Pre-Apprenticeship Program:
COMPLETE IF REQUESTING CREDIT (complete all that apply)
Previous Registered
Apprenticeship:
YES NO
If "Yes", Name of Occupation:
Name of Sponsor or Employer:
Previous Related Schooling: YES NO
School Name (attach transcripts):
Previous Related Employment: YES NO
Employer Name:
No. of months employed:
Please return to: Long Vang
Bureau of Apprenticeship Standards
620 W. Clairemont Ave
Eau Claire WI 54701
Telephone: (715) 874-4627
Fax: (715) 874-4603
Email: long.vang@dwd.wisconsin.gov
DETA-63-E (R.12/2019)
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Department of Workforce Development
Bureau of Apprenticeship Standards
APPRENTICE APPLICATION - VOLUNTARY EEO FORM
The information requested on this form is voluntary and gathered for compliance with state and federal affirmative action regulations governing
registered apprenticeship programs [Wis. Admin. Code Ch. DWD 296 and CFR Title 29 Part 30]. The information you provide will be utilized by your
program sponsor and state and federal apprenticeship staff for program administration but may also be used for secondary purposes [Privacy Law, s.
15.04(1)(m), Wis. Stats].
PLEASE COMPLETE:
Date
Name
Date of Birth
Race (select all that apply):
Gender (select one):
White
Black or African American
Asian
American Indian or Alaskan Native
Male
Female
Other
Native Hawaiian or other Pacific
Islander
Ethnic Group (select one):
Not Hispanic or Latino
Hispanic or Latino
Note: It is unlawful for a sponsor of a registered apprenticeship program to discriminate against an apprentice
or applicant for apprenticeship on the basis of race, color, religion, national origin, sex (including pregnancy
and gender identity), sexual orientation, age (40 or older), genetic information, disability, arrest or conviction
record, marital status, or membership in the armed forces. In addition, every sponsor is legally required to take
affirmative action to provide equal opportunity in apprenticeship and operate the apprenticeship program as
required under 29 CFR part 30 and the equal employment opportunity laws and regulations of the state of
Wisconsin.
DETA-18736-E (N. 12/2019)
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Department of Workforce Development
Bureau of Apprenticeship Standards
APPRENTICE APPLICATION - VOLUNTARY DISCLOSURE FORM
The information requested on this form is voluntary and gathered for compliance with state and federal affirmative action regulations governing
registered apprenticeship programs [Wis. Admin. Code § DWD 296.11 and Code of Federal Regulations Title 29 Part 30.11]. The information you
provide will be utilized by your program sponsor and state and federal apprenticeship staff for program administration, but may also be used for
reporting purposes [Privacy Law, s. 15.04(1)(m), Wis. Stats].
SELECT ONE:
Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I don't wish to answer
PLEASE COMPLETE:
Date
Name
Date of Birth
Why are you being asked to complete this form?
It is unlawful for a sponsor of a registered apprenticeship program to discriminate against an apprentice or
applicant on the basis of disability. However, because of your status as an apprentice or apprentice
applicant, you are being given the opportunity to disclose if you have a disability, or ever had a disability.
This form is used to evaluate the inclusion of individuals with disabilities in registered apprenticeship
programs. Because disability status may change or a person may wish to update their previous status, the
opportunity to disclose a disability is given during the application process, at the time of registration as an
apprentice, and on an annual basis during the apprenticeship. There is no penalty for disclosing a disability
now that you previously did not disclose.
How do I know if I have a disability?
You may be considered to have a disability if you have a physical or mental impairment or medical condition
that makes achievement unusually difficult, limits your ability to work, substantially limits a major life activity,
or if you have a history or record of such an impairment or medical condition. Disabilities include, but are
not limited to: blindness, deafness, cancer, diabetes, epilepsy, autism, cerebral palsy, HIV/AIDS,
schizophrenia, muscular dystrophy, bipolar disorder, major depression, multiple sclerosis (MS), missing
limbs or partially missing limbs, post-traumatic stress disorder (PTSD), obsessive compulsive disorder,
impairments requiring the use of a wheelchair or intellectual disability.
Apprentices: Return this form to your sponsor or mail it to the address below.
Sponsors: Enter this form into BASERS or submit it to your ATR or the address below.
Bureau of Apprenticeship Standards
Attn: AA/EEO
P.O. Box 7972
Madison, WI 53707
DETA-18736-E (N. 12/2019)
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APPRENTICE APPLICATION MECHATRONICS TECHNICIAN (Chippewa Valley Technical College)

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Completed 9 October 2020

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