Class A B

MnDOT-DEED Highway Heavy Construction Training & Placement (HHCTP)

Pre-application Program Form

Name:

First MI Last

Address:

Street Address City State Zip Code

Home Phone Number: Cell Phone Number:

E-mail:

Do you possess the following? (The following are required to establish program eligibility.)

Driver’s License? Yes No If yes, check classification: Class A Class B Class C Class D

Current Driver’s License Number State Exp. Date

Do you own an automobile? Yes No

Are you authorized to work in the U.S.? Yes No

Do you have High School Diploma/GED? Yes No

Please check the appropriate responses:

Gender: Female Male

With which racial/ethnic group do you identify? If the group appropriate for you is not listed, please check the one that comes closest.

Asian Native Hawaiian or Other Pacific Islander Black or African American

White or Caucasian Hispanic or Latino American Indian or Alaska Native

Two or more races

Return the pre-application by mail to the address below or email to ******.******@*****.**.**

CareerForce—Saint Paul

Sylvia Garcia, MnDOT-DEED HHCTP

540 Fairview Avenue North, Suite 103

St. Paul MN 55104

Further information about the program, please contact Sylvia Garcia at 651-***-****.

Applicant’s Signature: Date:

We are an Equal Opportunity Employer and Service Provider and are committed to recruitment, hiring, training and promotion of persons without regard to race, color, creed, religion, national origin, sex, marital status with regard to public assistance, disability, sexual orientation, veteran status or age, familial status, and local human rights commission activity. Access to and eligible for some specialized programs and services, such as the MnDOT-DEED HHCTP program, may be limited to specific populations or demographics. This document is available in alternative formats upon request, including e-form.

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