HVAC/R Application YCC HVAC/R Application First Name * Last Name * Phone Number * Email Address * Home Address * What type of housing situation best applies to you? * Public HousingOwn a HomeRentingShelterHomeless Race / Ethnicity * Black / African American Hispanic / Latino White / Caucasian Native American Other Sex * Your Age * 1718192021222324 Birth Month * 01-Jan02-Feb03-Mar04-Apr05-May06-Jun07-Jul08-Aug09-Sep10-Oct11-Nov12-Dec Birth Day * 12345678910111213141516171819202122232425262728293031 Birth Year * 20022001200019991998199719961995 Do you have a valid social security number (SSN) * Yes No Do you have a valid form of official photo identification? * Yes No This includes a Driver's license or a state ID. Do you currently receive any government assistance? If yes, what kind? (SNAP, housing, etc) * Have you completed high school? * Yes No No, but some GED No, but earned GED Are you on probation? * Yes No Are you on parole? * Yes No Have you held a job before? * Yes, I am working now. Yes, but I am not working now. No. If you are working now, please describe your current job. * Do you have any health conditions that we should know about? (Ex. diabetes, asthma, allergies, pregnancy) * reCAPTCHA Submit
