EMPLOYER SELECTED APPRENTICE REGISTRATION FORM

Which company referred you to this form?

Are you currently employed by the company for whom you'll be an apprentice?

YesNo

For SkillStorm Applicants:

Name of Client that you will be reporting to

Input your contracted hourly SkillStorm wage for OJT

$

CONTACT INFORMATION

First Name

Middle Initial

Last Name

Preferred Name

Pronouns

Other Pronouns

Personal Email

Work Email

Mobile Phone

Mailing Street

Do you have an apartment or unit to add?

YesNo

Apartment/Unit

Mailing City

Mailing State

Mailing Zip

Country

DEMOGRAPHIC INFORMATION

Date of Birth (mm/dd/yyyy)

Social Security Number

Gender

Race

Hispanic Ethnicity

DISABILITY INFORMATION

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment (or a history of such a condition) that substantially limits a major life activity.

Disabilities include, but are not limited to: autism, ADHD, anxiety, dyslexia, blindness, deafness, cancer, cerebral palsy, diabetes, major depression, missing limbs or partially missing limbs, PTSD. Definition of a disability

Do you have a disability?

If you need an accommodation please contact the Apprenti Access Team at accommodations@apprenticareers.org or (206) 513-7924.