SNAP Application

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 and Maryland Department of Human Services. This program reserves the right to check the accuracy of the information below.

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Were you referred to the program by a Maryland community college?

Please select which Community College referred you to the program:

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

How did you first hear about this program?

Please type the name of the high school that referred you:

Please type the name of the job fair you heard about us at:

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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

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: SNAP ELIGIBILITY

Do any of the following apply to you? (You may be asked to provide proof)

Are you in active status for the SNAP/Food-Supplement Program and do not receive Temporary Cash Assistance (TCA) benefits?

Are you listed as a household member on a SNAP/Food-Supplement Program application that is in active status and do not receive Temporary Cash Assistance (TCA) benefits?

Are you unemployed with no other source of income causing you to be eligible for SNAP/Food-Supplement Program and do not receive Temporary Cash Assistance (TCA) benefits?

SNAP Eligible?

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SECTION III: EDUCATIONAL BACKGROUND

Highest Educational Attainment

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SECTION IV: IT/CYBERSECURITY EXPERIENCE

Do you have work-related experience in IT and/or cybersecurity?

How many years of experience do you have in IT and/or cybersecurity?

Please describe your work-related experience in IT and/or cybersecurity:

Do you currently have any cybersecurity-related certifications?

Please select which of the following cybersecurity certifications you already have below. Hold the ctrl key on your keyboard and click on each applicable certification.

Please list any other certifications you may have:

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SECTION V: EMPLOYMENT INFORMATION

Are you currently employed?

Is your current position related to IT and/or cybersecurity?

Are you currently receiving unemployment insurance benefits?

Do you currently or have you ever held a United States Government Security Clearance?

Please describe your clearance history (to the extent you are able to):

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 VI: NEW EMPLOYMENT

This program is intended for individuals looking for new employment in the IT/cybersecurity field.

Are you looking for new employment in IT/cybersecurity?

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SECTION VII: 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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Grant Name (From Lead)

SECTION VIII: CONSENT

This program, curated by BCR Cyber, is funded by the Maryland Department of Labor's EARN Maryland Grant Program and Maryland Department of Human Services (DHS) Maryland Food Supplement Employment and Training (FSET) Program. As a recipient of FSET funds, this program is required by law to collect certain information from participants and to provide such information to DHS for reporting purposes. Such information will include but may not be limited to intake documentation, assessments, FSET eligibility verification, individual employment plans, progress notes, certifications, resumes, program performance status and placement status. By enrolling in this program, I grant permission to share my information with DHS and the Maryland Department of Labor, and I grant permission to the program to collect further information from me in the future, including information relating to my employment now and in the future. The conditions outlined in this document have been explained to me in an individual meeting and I understand and agree with these conditions.

By enrolling in this program, I grant permission to share any information contained in this application with DHS and the Maryland Department of Labor.

By signing below, I understand and agree with these conditions.

Consent Signature

Consent Date

Application Status

Applicant Source

Snap Eligible