Intake Assessment
Date
Please enter your Social Security Number so that the system can recognize/associate your Application with this form.
SSN
APPLICANT INFORMATION
First Name
Middle Initial
Last Name
FULL NAME
Phone Number
Email Address
BACKGROUND INFORMATION
Place of Birth
Date of Birth
Primary Language
Language Spoken at Home
Criminal Background?
Please select...
YES
NO
If you answered "YES" above, please explain:
Please describe any physical and/or medical issues that may impact your participation in the program (if none, "N/A"):
SNAP INFORMATION
Are you a SNAP Participant?
Please select...
YES
NO
Have you already provided your Proof of SNAP benefits to BCR Cyber?
Please select...
YES
NO
Proof of SNAP Benefits is required in order for your application to be reviewed. If you select "Yes", and we don't have your Proof of SNAP on file, your application will not be reviewed.
Please provide proof of SNAP
DEPENDENTS
Do you have any dependents?
Please select...
YES
NO
How many dependents do you have?
How old are your dependents?
Do you live with your dependents?
Please select...
YES
NO
Please list any Dependent Issues that may impact your program participation:
MOST RECENT EDUCATION
What is the highest grade you've completed?
Where did you complete it?
When did you complete it (what year)?
CURRENT EMPLOYMENT
Are you currently employed?
Please select...
YES
NO
Current Employer
Current Job Title
Current Job Duties
PRIOR WORK EXPERIENCE (Input your three most recent employment details below)
Work Experience #1 (
Employer
)
Work Experience #1 (
Duties
)
Work Experience #1 (
Start
Date
)
Work Experience #1 (
End
Date
)
Work Experience #1 (
Reason for Leaving
)
_________________________________________________________________________________________
Work Experience #2 (
Employer
)
Work Experience #2 (
Duties
)
Work Experience #2 (
Start Date
)
Work Experience #2 (
End Date
)
Work Experience #2 (
Reason for Leaving
)
_________________________________________________________________________________________
Work Experience #3 (
Employer
)
Work Experience #3 (
Duties
)
Work Experience #3 (
Start Date
)
Work Experience #3 (
End Date
)
Work Experience #3 (
Reason for Leaving
)
_________________________________________________________________________________________
PLEASE CHECK ANY/ALL OF THE FOLLOWING RESOURCES YOU HAVE BELOW:
Transportation
Internet Access
Laptop/Desktop Computer
AVAILABILITY & EXPECTATIONS
How many days a week are you available for training?
During what hours are you available?
What would be an acceptable IT/Cyber starting salary for you?
QUESTIONNAIRE
Please list your hobbies/interests:
How long do you think it should take for you to develop the skills needed to obtain an initial IT/Cyber position?
What is most important in your life?
What is your ideal job/career?
What are your most important goals?
Regarding your career, where do you want to be in five years?
Please describe the process/procedures you use to solve a complex problem. What steps do you take?
Form Type
Please select...
Intake Assessment
Individual Employment Plan
High School Diploma
Proof of SNAP
Form Status
Please select...
Not Started
Sent to Participant
Completed