Vermont HITEC

First Name *

Last Name *

Address Line 1 *

Address Line 2

City *

State *

Zip *

Daytime Phone *

Evening Phone *

Mobile Phone

Email Address * *An email address is required. If you need assistance creating one, please click the "Need Help?" link at the bottom of the page.

The Vermont HITEC ITAR program is an Equal Opportunity/Affirmative Action program. The information requested in this section is required to comply with state and federal grant guidelines. The information is CONFIDENTIAL and will be available only to authorized personnel for research and evaluation purposes.

Highest Level of Education Attained *

Gender * Male Female

CHECK ALL THAT APPLY

* You may be a dislocated worker if: You have been terminated or laid off from employment AND are eligible for or have exhausted unemployment compensation AND are unlikely to return to a previous industry or occupation, OR You have been terminated or laid off due to a plant closure, OR You were self-employed but are unemployed as a result of general economic conditions in the community, OR You are a displaced homemaker.

What is your current household size (including self)? *

Household Income *

Are you currently working with an agency or program? * Reach Up, Voc Rehab, WIA, ABAWD, TAA, etc.

If yes, with who?

Check all of the following that apply. If you selected Other, please include a statement in the following text field. Welfare recipient Food Stamp recipient Single Parent Other

Check all of the following that apply. If you selected Other, please include a statement regarding your disability in the following text field. Mental Physical Learning Other

Please check the field(s) you are interested in receiving notifications about.

Healthcare

Information Technology

Business Services

Advanced Manufacturing

How did you hear about Vermont HITEC? *

Applicant Interest Form