Career & Job Training Program Application

Applicant Information

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

County:

Please specify:

Email Address:

Primary Phone Number:

Race:

Ethnicity:

Please enter your Ethnicity:

Gender:

Date of Birth:

Veteran Status:

Are you currently without stable housing

Citizenship

Do you have a social security number?

What is your social security number?

Please upload a copy of your social security card below:

A copy of your official Social Security card is required. Handwritten versions are not acceptable.

Please upload a copy of your MN driver's license below:

Are you a U.S. citizen?

Country of Origin:

What is your primary language?

Do you have proof to work in the U.S.?

Please provide your A # and expiration date:

Date of arrival:

Immigration Status:

Immigrant - Any person lawfully in the United States who is not a U.S. citizen, U.S. national, or person admitted under a nonimmigrant category as defined by the Immigration and Nationality Act (INA) section 101(a)(15).

Refugee Status

Refugee - Status granted to an individual, prior to departure for and arrival in the United States, who has been determined by competent authority to be fleeing persecution or have a well-founded fear of persecution in their own country because of race, religion, nationality, membership in a particular social group or political opinion.

Emergency Contact Information

Name:

Relationship:

Phone:

Program of Interest

Are you a returning student?

Please specify the training you have completed with us below.

Which program are you interest in?

We apologize for the inconvenience, but our Certified Nursing Assistant (CNA) and Phlebotomy programs are currently full, and we are not accepting new applications at this time.

This training is likely to require students to undergo a background check and a physical exam.

How did you hear about us?

Please explain

Hidden

11/14/25: "Certified Nursing Assistant (CNA) (MUST be 16+)" & "Phlebotomy (MUST be 18+)" were removed because programs were full, per Johnny.

CONDITIONAL to CNA: "Please note that this training will require students to undergo a background check and a tuberculosis (TB) test."

Family/Income Status

Which of the following best describes your living situation?

Total number of family members living in your household:

Make sure to include yourself.

How many dependents under 18 are listed on your tax return?

What is your estimated annual household income?

Include your estimated income. If you have a spouse, include the total estimated annual income for both you and your spouse.

Are you currently receiving or has it been verified that you are eligible to receive benefits through the following programs? Select all that apply.

Minnesota Family Investment Program (MFIP)	Medical Assistance (MA)
Supplemental Security Income (SSI)/RSDI	Free and Reduced Lunch
Supplemental Nutritional Assistance Program (SNAP)	Refugee Assistance
General Assistance	None of the Above

Dislocated Worker & WIOA Participant

Are you a dislocated worker or a Workforce Innovation and Opportunity Act (WIOA) participant?

Please provide your caseworker's first and last name:

Caseworker's email address:

Caseworker's phone number:

MFIP Counselor

Name:

Email:

Phone Number:

HAP reserves the right to contact any county worker or organizational counselor for inquiries or requests related to program matters.

Certificate of Completion	GED	High School Diploma
Associate's Degree	Bachelor's Degree	Master's Degree
Doctoral Degree