Fillable Workforce Development Center Registration Form SOUTHWEST MISSISSIPPI COMMUNITY (Southwest Mississippi Community College)

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Workforce Development Center Registration Form SOUTHWEST MISSISSIPPI COMMUNITY (Southwest Mississippi Community College)

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The Workforce Development Center Registration Form SOUTHWEST MISSISSIPPI COMMUNITY (Southwest Mississippi Community College) form is 1 page long and contains:

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File type: PDF

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Revised June 20, 2016
SOUTHWEST MISSISSIPPI COMMUNITY COLLEGE
Workforce Development Center Registration Form
APPLICANT INFORMATION
First Name
M.I.
Last
Date of Birth:
SSN:
Mailing Address
State
Zip
County of Residence
Telephone No.
Email Address (optional)
ETHNIC/RACIAL GROUP
SEX
White/Caucasian
Black/African American
Hawaiian Native/Pacific Islander
Female
Asian
Male
American Indian/Alaskan Native
Hispanic/Latino
LEVEL OF EDUCATION
EMPLOYMENT STATUS
Please indicate which of the following best describes
your level of education:
Please indicate if you are currently:
Less than high school
Employed
High school degree/GED
Retired
Some college (no degree)
Unemployed
Associate degree
Bachelor degree
Graduate/Professional degree
EMPLOYMENT TYPE
TEMPORARY EMPLOYMENT
Please indicate if your current or most recent
employment is/was:
Please indicate if your current or most recent employment
is/was temporary:
Full time
Yes
Part time
No
Seasonal
EMPLOYER
Please provide name of your current or most recent employer:
DISCLAIMER AND SIGNATURE
SMCC does not disclose, give, sell, or otherwise share demographic information about workforce education course participants to any entity other than the Mississippi
Community College Board (MCCB). MCCB requires the collection of this information for the confirmation process of workforce training and uses the information
strictly for tracking purposes to ensure continued program effectiveness. Your signature authorizes your company to release this information to SMCC.
Date:
Signature:
Southwest Mississippi Community College does not discriminate on the basis of race, color, national origin, age, sex,
religion, or disability in its programs, activities or employment practices. The following persons have been designated to
handle inquiries and grievances regarding the non-discrimination policies: Mrs. Rhonda Gibson, Director of Disability
Support Services, 601-276-3885; Dr. Bill Ashley, Vice President for Student Affairs, Title IX Coordinator, and Director
of Athletics, 601-276-3717, 1156 College Dr., Summit, MS 39666.
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Workforce Development Center Registration Form SOUTHWEST MISSISSIPPI COMMUNITY (Southwest Mississippi Community College)

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Completed 26 July 2020

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