2012 Brownfield Application by 398oj5


									                                                         Application Directions
                                                      Brownfield/ Environmental Field
                                                           Technician Program

                 2012 Brownfield /Environmental Field Technician Program
                                February 21- April 10, 2012
                       Butler Tech Public Safety Education Complex
                             Monday- Friday, 8:00 AM- 5:00 PM
                                                     Orientation to Non-traditional Occupations for Women
In order to enroll in this program, you must be at least 18 years old, eligible to work in the US,
have a high school diploma or GED, have a valid driver’s license, and be drug free. For training
at Butler Tech, you must be a resident of Butler or Warren County. Residents of Hamilton
County should apply for the program at Hamilton County SuperJobs.

You must then complete the following steps:

   1. Submit the Application for Participation including a copy of your driver’s license, a
      personal statement, and letters from references to Butler Tech. Applications will be
      reviewed on a first come, first serve basis, but should be submitted no later than
      February 1, 2012. Applications may be delivered in person or mailed to Bob Hasselfeld,
      Butler Tech PSEC, 5140 Princeton-Glendale Rd, Liberty Twp, OH 45011. It may also be
      faxed to Bob Hasselfeld at 513-844-8946.

   2. To see if you may qualify for support services such as child care, etc., reach out to your
      county Job and Family Services agency.

   3. Score at a minimum 7th grade level for reading and math on the TABE (Test of Adult
      Basic Education) exam. If you have an associate’s or bachelor’s degree, you do not
      have to take the TABE exam. This exam and its preparation classes are available at
      area ABLE programs. We recommend that you attend four preparation classes to make
      sure you are ready for the exam. There is an ABLE location in Butler Tech’s D. Russel
      Lee building, 3603 Hamilton-Middletown Rd. Current TABE registration and testing
      dates at the Butler Tech D. Russel Lee location are Oct. 4 and 18; Nov. 1, 15 and 29;
      and Dec. 13. More testing dates will be available in January. Call ABLE at 513-420-4520
      for more information or to confirm testing dates. Please let them know you are with the
      Brownfield program and would like to prepare and take the TABE test.

   4. Provide a state criminal background check. Applicants who have a felony will be
      considered on a case-by-case basis.

   5. You will be scheduled for an interview. Rounds of interviews will begin in December
      2011 and continue through February 10, 2012.

   6. Once your application has been approved for the second round, you will be given
      additional information to take a drug test. Butler Tech must receive passing results for
      you to continue through the process.

   7. You will then take a physical exam to determine your physical fitness for the type of jobs
      for which this program prepares you.

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8. Within five business days of completion of this process, you will receive information on
   the status of your admission to the program via email. If you do not have an email
   address, you may be contacted by phone but it is highly recommended that you create
   an email address to assist with employment after the program.

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                                                          Application for Participation
                                                                     Brownfield/ Environmental Field
                                                                          Technician Program
                                                                    Orientation to Non-traditional Occupations for Women

Today’s date__________

PRINT Name _________________________________________________________________________
                            First                  Middle Initial                          Last

Date of Birth: _____/_____/_____ Age ____________

Ethnicity: ___ Hispanic/Latino             Race:   _____Am. Indian       _____ Asian      _____ Black /African Am.
            ____ Not Hispanic/Latino               _____ Multiple        _____ White      _____ Other

Gender:     ___Female                    ___Male

Street Address_________________________________________________________________________

City _________________________________________, Ohio                     Zip _____________________________

Email address ________________________________________________________________________

County ___________________               Neighborhood or Ward __________________________

Phone ________________________________ Alternate Phone _________________________________

Emergency Contact
Contact Name___________________________________________ Relationship______________

Phone__________________________________ Alternate Phone___________________________
I attest that I have a High School Diploma or GED received from:

School _______________________ Date________________

What is your highest education level completed?:
__HS/GED _ Some college              _College degree: College____________ Degree_____

Eligibility to Work in US
I hereby certify that I am (check one of the following):
     A citizen or national of the United States
     A lawful permanent resident
     An refugee, asylee, parolee, or other immigrant authorized by the Attorney General to work in the
      United States

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Criminal Record

_____Felony _____Felony and Misdemeanor ____Misdemeanor _____No Criminal Record
Valid Driver’s License
Do you have a valid driver’s license? ___Yes, DL# _________________                  __No
Please provide a copy of your driver’s license with your application.

If appropriate, please list the number of points or types of violations on your driving record:

Employment/Economic Status
__ Employed: Salary or Hourly Wage:____________; Hours Worked per Week:___________

Household Income $_______________         Household Size___
How did you hear about the Brownfield/ Environmental Technician program?

_____Career Counselor          _____ Agency/Other (specify_________________________)
_____Friend/ Relative          _____Referral              _____Internet
_____Walk-in                   _____TV                    _____Newspaper

Please submit signed reference letters from three individuals. The individuals may also
send letters directly to Butler Tech, attention Brownfield Training Program, via fax at 513-
844-8946 or 5140 Princeton-Glendale Road, Liberty Township, OH 45011

I certify that my responses on this application and in my personal statement are true and
complete to the best of my knowledge.

If this application leads to acceptance to the Brownfield Job Training Program, I understand
that any false or misleading information in my application or interview may result in my
release from the program.

_________________________________                             ___________
Signature                                                     Date

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Personal Statement:
In 250 words or less, tell us why you would like to participate in this training. If you have any
experience as a laborer or in the construction field, please feel free to mention in your statement.
You may write your statement below or attach it to this application.

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                     Do Not Write Below This Line. Office Use Only

Pre-Entrance Score

TABE:        Reading______          Math________

Work Keys:   Reading______          Math________         Locating Information _______

Background Check Status:   _______________, Initialed:

Physical Exam Status: ____________________, Initialed:

Drug Screen Status: ______________________, Initialed:

Reference Check: _____________________

Interview status: _______________________

__Admitted on__________

__Rejected on _________ Reason:

__Waitlisted on _________ Reason:

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