Day Training Program Application Home $ Day Training Program Application Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Phone Number *Consent to use this number in mass text messaging *EZ TextingIn case of emergency, notify: *RelationshipEmergency Contact Number *To be eligible, you must be an enrolled member of the Mississippi Band of Choctaw Indians. *Tribal Enrollment NumberHave you ever been convicted of a felony or misdemeanor other than a minor traffic offense which has not been expunged or sealed by a court? *YesNoIf yes, list the date, city, charge and dispositionList any work experience or abilitiesList any certificates or awardsChoctaw - How would you rate your language reading and writing skillsFluentGoodFairEnglish - How would you rate your language reading and writing skillsFluentGoodFairSpecify any other languagesName of high school attendedCity/State of highschool attendedDid you graduate from highschool?YesNoGED?YesNoName of college attendedCity/State of college attendedDid you graduate from college, or complete your degree?YesNoNumber of years in college?Are you currently employed?YesNoIf "No," name of last employmentIs applicant receiving any other type of income?YesNoIf "Yes," please name the following source of income receivedPlease describe or list any disabilities or limitations that you may have. This will help provide the program information concerning yours needs in finding placement:CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM I certify that all of the information provided in this application is true and complete to the best of my knowledge and I authorize investigation of all statements contained in this application, including a criminal background, as applicable. I understand that any false or incomplete information may disqualify me from further consideration and may result in my immediate dismissal if discovered at a later date. I authorize the investigation of any of all statements contained in this application and also authorize any person, school, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I have read, understand, and agree to the above statements. Signature Clear Signature BACKGROUND INVESTIGATION AUTHORIZATION/ DISCLOSURE I authorize and instruct all corporations, companies, educational institutions, persons, law enforcement agencies, Workers’ Compensation agencies, criminal, civil, and federal courts, and former employers to release information they have about me and release them from any liability and responsibility from doing so. Any copy of this authorization shall have the same authority as the original. Signature Clear Signature The following information is required for background investiagation authorization/disclosure. Name *FirstMiddleLastMaiden or other name *Social Security Number *Date of birth *Driver license number and state *Consent to release client and/or student information I allow and authorize the Day Training Program to discuss and/or release information from my record to other programs in the Workforce Development Program. The Workforce Development Programs are Day Training Program, Adult Basic Education Program, Vocational & Employment Services, Employment & Training Services and Vocational Rehabilitation Services. I authorize the Program Staff members in the Workforce Development Program to discuss my information or record for the purpose of advancing my education, job training, and job placement possibilities. I further understand tha information from my record which will not identify me will be used for reporting purposes for grants and budget purposes. Client or student name *FirstMiddleLastClient or student signature * Clear Signature Submit Tribal Profile | Tribal Directory | Employment ©2024 Mississippi Band of Choctaw Indians