Automated People Mover Intake Form
The purpose of this Intake Form is to gather information about you to assist us in connecting you with the best resources for getting you started towards building a career in construction. To get started, you will need to enroll or have graduated from a pre-apprenticeship or apprenticeship program. Through our network of community and agency partners, you will have access to a range of programs and resources available to help you address employment barriers so that you are able to achieve your construction career goals.
Non - Binary
Date of Birth
Home Phone Number
Cell Phone Number
0 Through 8th Grade
9 - 12 Non HS Graduate
Other Than Honorable
Helmets to Hardhats Registered
Not a Veteran
American Indian/Alaska Native
Native Hawaiian/ Other Pacific Islander
Declined to Disclose
Have you attended College?
What is your College Enrollment Status?
Local Trade Union
Local Union #
Apprentice Period #
Journeyman # yrs.
Are you registered with a Worksource Center/EDD/AJCC
Please list the Worksource Center/EDD/AJCC you are registered with.
Safety Training Completed
10 Hr OSHA
30 HR OSHA
40 HR HAZWOPER
80 HR HAZWOPER
How may years of construction experience do you have?
What trades do you have construction experience in?
Have you attended a Pre Apprenticeship Training Program?
LATTC ARP - PROP 39
HOMEBOY INDUSTRIES - PROP 39
FLINTRIDGE CENTER - ARP
Barriers to career goals & educational success
EMANCIPATED FROM FOSTER CARE SYSTEM
LIMITED WORK EXPERIENCE
TRANSITIONAL OR UNSTABLE HOUSING
NEED FOR WORK TOOLS/EQUIPMENT
LACKS JOB SEEKING SKILLS
LIMITED LABOR MARKET AWARENESS
70% OF THE LOWER LIVING STANDARD INCOME LEVEL - SINGLE $10,824.00
70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 2 PERSON HOUSEHOLD $17, 737.00
70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 3 PERSON HOUSEHOLD $24,352.00
70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 4 PERSON HOUSEHOLD $30,063.00
70% OF THE LOWER LIVING STANDARD INCOME LEVEL - 5 PERSON HOUSEHOLD $35,475.00
Briefly explain your barriers.
Do you meet any of the following criteria? Please check all that apply.
Homeless or residing in a transitional home.
Criminal Record or Involvement with the Criminal Justice (Misdemeanor or felony)
Custodial single parent
Receiving public assistance
Lacking a GED or High School Diploma
Emancipated from Foster Care System
Reside in household with total income less than 50% of the median income (AMI)
Veteran Iraq/ Afghanistan War (1999 to present)
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This form was created inside of PDA Consulting Group.