BuildUp Intake Application
Contact Information
First Name
Middle Name Initial
Last Name
Street Address
City
Zipcode
Phone Number
Email Address
BuildUp Eligibility
Are you enrolled in a pre-apprenticeship program or have you completed a pre-apprenticeship program (TRAC, ANEW, PACT, CTAP, Palmer Scholars)?
Yes
No
What Pre-Apprenticeship program are/were you apart of?
Please select...
PACT
ANEW
Palmer Scholars
CTAP
TRAC
Carpenters Pre-Apprenticeship
Iron Workers Pre-Apprenticeship
SW Electrical Pre-Apprenticeship
Are you already an apprentice?
Yes
No
What is your Apprentice ID (ARTS#)?
What trade are you in?
Please select...
Laborer/LIUNA
Iron Workers
Sheet Metal
Electricians
Cement Masons
Plasterers
Painters
Glaziers
Carpenters
Boilermakers
Plumbers and Pipe Fitters
Inland Empire
Teamsters
Other
Operating Engineers
Please specify
Are you currently receiving any of the following services? (Please check all that apply?)
SNAP/Food Stamps
Unemployment
TANF/Workfirst
SSI/SSDI
Receive government assistance for housing
Any other support services
I DO NOT receive any services
How do you best describe yourself?
American Indian/Alaska Native
Black or African American
White
Asian
Native Hawaiian or Pacific Islander
Hispanic, Latino, Spanish Origin
More than one race
Prefer Not to Say
Are you enrolled in a Federally Recognized Tribe?
Yes
No
Name of Federally Recognized Tribe?
Tribe Enrollment # (Required if you said yes, you are enrolled in a Federally Recognized Tribe)
Are you married?
Yes
No
Do you have dependent children?
Yes
No
Please indicate their names and ages
What is your household size (including yourself)?
What is your household income?
$0 - $25,000
$25,000 - $75,000
$75,000 - $100,000
$100,000 and above
What is your current household type?
Single adult
Couple, no children
Two parent family
Single minor
One parent family
Foster family
Employment Information
Have you worked in the last 30 days?
Yes
No
Are you currently working?
Yes
No
What was/is your hourly wage?
What is your current employment status
Employed full time
Employed part time
Currently on unemployment
Not employed, looking for work
Other
If you are employed, who is your contractor/employer
Are you receiving Basic Food assistance or have you applied?
Yes
No
Education Information
What is your current education status?
Currently attending HS or GED program
High School diploma
Some college
Technical or Vocational Certificate
Masters Degree
9th - 12th grade, no diploma
GED certificate
Associates Degree
Bachelors Degree
Self Identification Information
Date of birth
What is your gender?
Male
Female
Non-Binary
Transgender
Other
Prefer Not to Say
Are you a veteran?
Yes
No
What is your immigration status?
Citizen
Legal Resident
Immigrant
Refugee
Do you have a drivers license?
Yes
No
What is the status of your drivers license?
Valid
Suspended
Never licensed
Court Involvement
Have you ever been justice involved?
Yes
No
Prefer Not to Say
Are you currently on probation or in Work Release?
Yes
No
How did you hear about BuildUp
Referral
Friend/Family
Pre-Apprenticeship Program
Apprenticeship program
Union
Social Media
Event
Jobsite advertisement
What support services are you needing assistance with?
Contact Information