Level Up Interest Form

Are you currently employed?

Yes (Full Time)

Yes (Part Time)

No (Unemployed)

Where do you currently work?/If not what are your current circumstances?

Date of Birth

(Must be 18 years old or older to participate in this program.)

I live in one of the following Indiana counties

Jasper County

Lake County

Newton County

Porter County

Starke County

Check all that apply

I have a valid Indiana Drivers License

I have my own transportation

I have served or am currently serving in the U.S. Armed Forces

I am interested in training in the following industry/field?

If you are unsure, type I don't know.

Preferred Language

English

Spanish

Other…

Please provide preferred language

Contact Information

First Name

Last Name

Phone

Address

Address 2

City

State

Zip Code

Which race or ethnicity best describes you?

American Indian or Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

Latino / Hispanic

Middle Eastern

White / Caucasian

Mixed / Multiple ethnicity

To which gender identity do you most identify?

Man

Woman

Prefer Not to Answer

Best time to call

Morning

Afternoon

Evening