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Application2017 (Columbia College)

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Columbia College

Apprenticeship

Initiative

Application

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The Columbia College Apprenticeship Initiative is a grant funded program. Its mission is to provide students in the

program with the tools needed to earn an Associate of Science Degree while gaining on-the-job training in an Apprentice

position. If you need help filling out this application or have any questions please contact Jen Bick at 209-588-5269

bickj@yosemite.edu

PLEASE PRINT CLEARLY (All information will be kept confidential)

Contact Information

Name:

(Last ) (First) (Middle Initial)

Address:

Number and street City State Zip

E-mail:

Home phone:

Cell:

Best Time

to call:

How did you learn about this program?

Year of high school graduation:

or Year of GED:

Are you interested in an Apprenticeship Program in:

 Hospitality Mangement  Child Development

 Automotive

Technology

Other Colleges/Universities attended (names/dates):

Have you completed college units?

If yes, how many?

 Yes  No

What are your educational goals? (circle ALL that apply)

Certificate 2-year degree (AA/AS)

Transfer to a 4-year College

Undecided

Are you a resident of California?

 Yes

 No

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Employment History

Please provide the following information that pertains to your employment history. You may

include volunteer work.

Employers Name:___________________________________________________________________________________

Supervisors Name:___________________________________________________________________________

Address:___________________________________________________________________________________

Job Title:___________________________________________________________________________________

Job Duties:__________________________________________________________________________________

Reason for Leaving:__________________________________________________________________________

Dates of Employment:________________________________________________________________________

Employers Name:____________________________________________________________________________________

Supervisors Name:___________________________________________________________________________

Address:___________________________________________________________________________________

Job Title:___________________________________________________________________________________

Job Duties:_________________________________________________________________________________

Reason for Leaving:__________________________________________________________________________

Dates of Employment:________________________________________________________________________

Employers Name:____________________________________________________________________________________

Supervisors Name:___________________________________________________________________________

Address:___________________________________________________________________________________

Job Title:___________________________________________________________________________________

Job Duties:_________________________________________________________________________________

Reason for Leaving:__________________________________________________________________________

Dates of Employment:________________________________________________________________________

Other training:_______________________________________________________________________________

Columbia College and our Industry Partners are Equal Opportunity Employers.

Read, Sign and Date.

I verify that the information on this form is correct and complete. I understand that my acceptance to the Columbia

College Apprenticeship Initiative depends on the accuracy of my answers. I authorize the Columbia College

Apprenticeship Initiative to request copies of transcripts, transfer information, and employment references, pertinent

to my future educational performance. All information will be kept confidential.

_______________________________________ ___________________

Student Signature Date

_______________________________________ ___________________

Parent/Guardian Signature (**required for all students under 18 years of age)

Date

Submit application to: Jen Bick, bickj@yosemite.edu, 11600 Columbia College Dr. Sonora, CA 95370,

209-588-5269

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COLUMBIACOLLEGEAPPRENTICESHIPINITIATIVE

INSTRUCTIONS:Useapenwithblackorblueinktocompletethisform.Formultiplechoicequestions,makeheavydark

marksthatfilleachsquarecompletely.

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1. _____________________________________________

FirstName MI LastName

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2. Today’sDate:|_|_|/|_|_|/|2|0|1||

 MonthDayYear

2. DateofBirth:|||/|||/|||||

 MonthDayYear

3. Gender:

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1□Male

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2□Female

4. AreyouofHispanicorLatinoheritage?

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1□Yes

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0□No

5. Whatisyourrace?

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PLEASECHECKALLTHATAPPLY

 1□AfricanAmerican/Black

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2□AmericanIndian/AlaskaNative

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3□Asian

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4□NativeHawaiian/OtherPacificIslander

 5□White

 6□SomeOtherRace(Writein):_____________________ 

6. WhatistheMAINlanguageyouspeakathome?

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MARKONEBOX

 1□English

 2□Spanish

 3□Anotherlanguage(specify):

7. Whatisthehighestlevelofeducationyouhaveachieved?

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1□ DidnotcompleteHighSchool

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4□ HSDiploma

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5□ GED

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6□ CollegeCertificate(i.e.lessthan2yearcertificate)

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7□ Associatesdegree(AA/AS)

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8□ Bachelor’sdegree(BA/BS)

9□ Graduatedegree

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10□ Other(Writein):____________________

8. Doyouhaveadisability?

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1□ Yes,Ihaveadisability

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0□ No,Idonothaveadisability

9. HaveyouservedonActiveDuty(otherthanreservestatus)

intheU.S.ArmedForces?

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1□ Yes

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0□ No

10. Pleasecheckeachofthefollowingsourcesofassistancethat

anyoneinyourhouseholdreceivedinthepastmonth.

 MARKALLTHATAPPLY

 1□ TANF(Cashassistance)

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2□ SSIorSSDI

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3□ GeneralRelief

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4□ SNAP(FoodStamps)

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5□ UnemploymentCompensation

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6□ Other(Writein): 

 0□ IFNONE,MARKHERE



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FORSTAFFUSEONLY

ID#

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Application2017 (Columbia College)

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