EARN COMET - INCUMBENT

Answer questions completely except for those which do not apply. Information is kept confidential. By enrolling in this program, I grant permission to share my information with the Maryland Department of Labor. This program reserves the right to check the accuracy of the information below.

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Please select which Community College referred you to the program:

If "Other", please type the name of the Community College that referred you:

SECTION I: PERSONAL INFORMATION

First Name

Middle Name

Last Name

Full Name

Street Address

City

State

Zip Code

County

Gender

Social Security Number

Date of Birth

Email

Phone

Do you check email often?

Race

Races (Two or more) - please hold ctrl key and click on each applicable race:

If other Race(s), please specify

National Origin

If other, please specify

Are you a state or local government employee?

Have you served or are you currently serving in the military?

Is your spouse currently serving or has he/she previously served in the military?:

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SECTION II: EDUCATIONAL BACKGROUND

Highest Educational Attainment

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SECTION III: EMPLOYMENT INFORMATION

Are you currently employed?

Are you currently receiving unemployment insurance benefits?

Please provide your current or most-recent employment information.

Name of Employer

Job Title

Start Date

End Date

Hourly Wage

Average number of hours worked per week

Are/were you offered health benefits?

Please list additional skills or hobbies:

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SECTION IV: EMERGENCY CONTACTS

Emergency Contact #1

First Name

Last Name

Phone

Street Address

City

State

Zip Code

Nature of Relationship

Emergency Contact #2

First Name

Last Name

Phone

Street Address

City

State

Zip Code

Nature of Relationship

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SECTION V: CONSENT

This program is funded by the State of Maryland’s EARN Maryland Grant Program, administered by the Maryland Department of Labor. As a recipient of EARN Maryland funds, this program is required by law to collect certain demographic information from training participants and to provide such information to Labor for reporting purposes. Any demographic information provided to Labor will not contain personal identifiable information. By enrolling in this program, I grant permission to share my demographic information with Labor. I understand and agree with these conditions.

Consent Signature

Consent Date

Application Status

Applicant Source

Snap Eligible

Contact Information