This 11-week (300 hour) training program consists of the following courses

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Florida State College at Jacksonville and the City of Jacksonville are pleased to announce that the United States Environmental Protection Agency (EPA) has awarded an Environmental Workforce Development & Job Training Grant for our community. This job training program will provide environmental job training that will facilitate the creation of employment in emergency response, Superfund & Brownfields site remediation and other environmental and green industrial jobs. This program targets unemployed or under-employed (20 hours or less a week) participants in North Florida.

This 11-week (300 hour) training program consists of the following courses Advanced Training:

 OSHA 29 CFR 1910.120: Hazardous Waste Operator and Emergency Responder HAZWOPER

 Florida DEP Storm water, Erosion, Sedimentation Control Inspector  OSHA Disaster Site Worker

 Environmental Sampling & Analysis  OSHA Construction Safety

 OSHA General Industry Certification  OSHA Maritime Industry

 FEMA: National Incident Management System (NIMS) IS-00700.a Certificate

 FEMA: Introduction to Incident Command System IS100 Certificate

 EPA 24 Hr. Hazardous Material Technician  Collections and Waste Water Training  Asbestos Worker Certification

 EPA Lead Renovator, Repair & Paint (RRP)  American Red Cross First Aid, CPR&AED  OSHA Blood Bourne Pathogens

Awareness Training:

 Environmental Justice Overview

 Solid Waste: Deconstruction & Recycling, Green Remediation Technologies

 Environmental Math & Chemical Safety

 OSHA Confined Space Entry

 Green Technology Industry: Urban Agriculture

 Leaking Underground Storage Tank (LUST)

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Application Process

Step 1:

Complete and submit this application and provide copies of required identification listed in the application for screening, by one of the following methods:

Email to: [email protected] Project Coordinator: Sarah Ashbrook Drop off or mail to: Florida State College at

Jacksonville Urban Resource Center Rm102L Attention: EWD&JT Team 601 West State St Jacksonville, Fl. 32202

Step 2:

Attend a scheduled mandatory Environmental Workforce Development & Job Training Orientation and information session (questions & answers).

Step 3:

Attend a scheduled interview process with the Environmental Training Team.

Step 4:

You will be scheduled to take a Test for Adult Basic Education.

Step 5:

If you do not pass the Test for Adult Basic Education, you may attend remedial education and Reapply for future classes.

Step 6:

Pass the Test for Adult Basic Education.

Step 7:

Pass a drug urinalysis screening.

Step 8:

Upon completion of the previous steps, you will have a final interview process and be notified if selected for the next available course. This Job Training program is a Selective Admission Program.

Participant Prerequisites

 Must be unemployed or under employed.

 Must be 18 years of age.

 Must have a high school diploma or high school equivalency certification.

 Must be physically fit and able to lift at least 30 pounds.

 Must be able to work in confined areas (not claustrophobic)

 Must consent to a drug urinalysis test

 Must pass a test for adult basic education (T.A.B.E)

 Must consent to a criminal background check

PLEASE CONTINUE AND CAREFULLY COMPLETE THE PARTICIPANT APPLICATION. SUBMIT ONLY THE COMPLETED APPLICATION PORTION OF THIS PACKET ONLY.

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Page 1

U.S. EPA Environmental Workforce Development & Job Training Program Application

Must complete all four pages of this application form

PLEASE PRINT CLEARLY

Full Name: ____________________________________________________________________ Today’s Date:_______________ Gender (Circle One) Male | Female

Present Address:____________________________________________ ____________________ City __________________________________ State ________________ Zip Code ___________ Phone: Day _______-__________-_________ Evening ________-_____________- ___________ Email Address: _________________________________________________________________ Date of Birth_________________________ Country of Birth: ___________________________ Social Security Number*: _________________________________________________________ Ethnicity (optional) : African American | Hispanic | Caucasian | Other _____________________ American Citizen Yes | No If no, green card # ________________________________________ Number of people in household related by blood, marriage, or decree of court ______________ Are you a military veteran? (Circle One) Yes | No Type of discharge: _________________________

If yes, what branch of military did you serve in? _______________________________________ Are you registered with Work Source? (Circle One) Yes | No

In case of an Emergency, Contact Information: ________________________________________ Relationship: ___________________ Phone: __________-_______________ - ______________

EDUCATION

(Must possess one of the following)

High School Equivalency Certification: Yes |No | High School Diploma: Yes | No

College: Yes | No | College Attended ________________________________________________ Degree: Yes | No | Degree Obtained ________________________________________________ Do you owe money to Florida State College at Jacksonville? Yes | No

Are you currently attending school? Yes | No | Name of School: ___________________________ Are you interested in pursuing a degree? Yes | No

EMPLOYMENT STATUS

(Circle one)

1. Currently unemployed Yes | No

2. Currently under employed (less than 20 hours per week) Yes | No 3. Currently employed part-time (20 or more hours per week) Yes | No 4. Currently employed full-time Yes | No

5. Temporarily laid-off from current job Yes | No

How did you learn about our program? _______________________________________________ Personal referral (please give a name) _______________________________________________ Organization or company referral ___________________________________________________ Other _________________________________________________________________________

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WORK HISTORY

How many jobs have you held? ___________

1. Current employer / Previous employer / Employer’s

Company Name: ________________________________________________________________________ Company Address: _______________________________________________________________________ Your job title and responsibilities: __________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Supervisor / Phone Number: ________________________________

Full-time

o

Part-time

o

Number of hours per week? ____________

Start Date ________ /__________ /_________ End Date ________ /___________ /________ How much did you earn per hour? ________________

What did you like most about the job?

______________________________________________________________________________________ ______________________________________________________________________________________ What did you like least about the job?

______________________________________________________________________________________ ______________________________________________________________________________________ Reason for leaving ______________________________________________________________________ ______________________________________________________________________________________

Company Name: ________________________________________________________________________ Company Address: ______________________________________________________________________ Your job title and responsibilities: __________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Supervisor / Phone Number: ________________________________

Full-time

o

Part-time

o

Start Date ________ /_________ /_________ End Date __________ /__________ /________ How much did you earn per hour? ________________

What did you like most about the job?

______________________________________________________________________________________ ______________________________________________________________________________________ What did you like least about the job?

______________________________________________________________________________________ ______________________________________________________________________________________ Reason for leaving ______________________________________________________________________ ______________________________________________________________________________________

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Page 3

Company Name: ________________________________________________________________________ Company Address: ______________________________________________________________________ Your job title and responsibilities: __________________________________________________________ ______________________________________________________________________________________ Supervisor / Phone Number: ________________________________

Full-time

o

Part-time

o

Start Date ________ /_________ /_________ End Date __________ /__________ /_______ How much did you earn per hour? ________________

What did you like most about the job? ______________________________________________________ ______________________________________________________________________________________ What did you like least about the job? _______________________________________________________ ______________________________________________________________________________________ Reason for leaving ______________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

JOB TRAINING

Would you be willing to travel and/or relocate for employment? (Circle One) Yes | No

Do you have a valid drivers license? (Circle One) Yes | No

Have you been through any other programs, job training, or otherwise? If so, please list the program name and dates ______________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Please explain your knowledge of environmental cleanup.

______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Why do you think you would be an EXCELLENT candidate for the Job Training program?

______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

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PLEASE STAPLE OR PROVIDE COPIES OF THE FOLLOWING DOCUMENTATION

ALONG WITH YOUR APPLICATION.

• Florida Driver’s License or Florida Identification Card with Correct Address • Social Security Card Green Card, if not a U.S. Citizen

• Birth Certificate if U.S. Citizen

• High School Equivalency Certification: High School , College Diploma

DISCLOSURE STATEMENT

I hereby certify, to the best of my knowledge, the above information is true. I agree and understand that any willful misstatement of facts may cause forfeiture of my status in the program and could be cause for legal action. I understand the information is subject to verification and agree to provide such documentation as required. I understand disclosure of my SS# is voluntary.

Print Name: ____________________________________ Date: ________/___________/________________ Signature: _______________________________________________________________________________

Grant is funded by the United States Environmental Protection Agency. *Collection and Use of Social Security Numbers (http://www.fscj.edu/ssn)

Florida State College at Jacksonville provides equal access to education, employment, programs, services and activities and does not discriminate on the basis of age, race, color, national origin, sex, disability, religious belief, or marital status. The College Equity Officer has been designated to handle inquiries regarding the non-discrimination policies and may be contacted at [email protected]. Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Flori-da or elsewhere. FloriFlori-da State College at Jacksonville is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award the baccalaureate and associate degree. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097, or call (404) 679-4500 for questions about the accreditation of Florida State College at Jacksonville. The Commission is to be contacted only if there is evidence that appears to support an institution’s significant non-compliance with a requirement or standard.

Staff member Name: _____________________________ Date: ________/___________/ _______________ Signature: ______________________________________________________________________________