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Helping the disabled obtain Information Technology training for today's marketplace

Candidate Information Form

This form is for students interested in applying for the EmployMe! training program.
Please fill out the form carefully and completely.
We will use this information to contact you about your eligibility for this program.

Contact Information

First:
Last:
Social Security Number: *
Street:
City:
State:
Zip Code:
County:
Home Phone:
Cell Phone:
FAX: (if available)
E-Mail: (if available)
In Case of Emergency, Contact: (First and Last Name)
Telephone Number: (Emergency Contact)
 

About You

Date of Birth: (mm/dd/yyyy)
Sex:
Ethnicity: **
(Note: A Hispanic or Latino is a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)
Race:
Number of Years of Education: (first grade is year one; first year of college is year 13)
 

Employment Information

Are you currently employed?  Yes  No
If you are currently employed, please enter your occupation:
 

Disability Information

Please describe your disability:
Do you have access to a computer?
Do you have access to the Internet?
Do you have any computer experience?
Will you require any adaptive technology support?
 
By submitting this form, you acknowledge that the information you have provided is accurate and true.
Applicant's Initials:
Date: Month   Day   Year
 

You may also fax this to 973-596-3288 or mail it to
NJIT, Division of CPE
University Heights
Newark, NJ 07102

*Your social security number will be stored securely and not disclosed to anyone who is not an employee or contractor of NJIT. Providing your social security number is voluntary. It will help the program evaluate the effectiveness of the services it provides so that it can make the program as useful as possible to future students.)

** conforms to US Department of Educations' s new procedures for collecting information on race/ethnicity
Division of Continuing Professional Education, University Heights, Newark, NJ 07102
Course Pricing, Course Offerings, Requirements and Course Schedules are all subject to change without notice.