BCR Cyber CISSP 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. This program reserves the right to check the accuracy of the information below.

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Were you referred to this program by your employer?

Please type the name of the employer that referred you:

Were you referred to this program by a 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:

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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: EDUCATIONAL BACKGROUND

Highest Educational Attainment

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SECTION III: IT/CYBERSECURITY EXPERIENCE

You must have a minimum of five years work experience in cybersecurity in order to qualify for this training.

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 IV: 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 V: 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 VI: 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