2. 
3. PORT ARTHUR ECONOMIC DEVELOPMENT CORPORATION YOUTH EMPLOYMENT PROGRAM - 2023 EMPLOYMENT APPLICATION
   
5. Deadline April 10, 2023
7. 2023 Youth Employment Program Policies and Procedures
   Read YEP Policies and Procedures
9. DATE OF APPLICATION:
   DATE OF APPLICATION:
10. SS# (last 4 Digits): *
12. Name*
    Last, First, Middle Initial
13. Email Address
15. Address*
    Street Number and Name, Apartment Number (if applicable)
17. City*
18. State*
19. Zip Code*
21. Alternate Address
23. City
24. State
25. Zip Code
27. Home Phone Number
28. Mobile Number
30. Gender*
    -- Select One --FemaleMale
34. EDUCATION
36. High School
37. Graduate/Degree*
    -- Select One --High School Diploma/GEDCertificateAssociate'sBachelor'sMaster'sPhDOther
39. Address
41. City
42. State
43. Zip Code
45. College or University
46. Graduate/Degree
    -- Select One --Associate'sBachelor'sMaster'sPhD
48. Address
50. City
51. State
52. Zip Code
54. Specialized Training, Trade School, etc.
56. Address
58. City
59. State
60. Zip Code
62. Other Education
63. List any education different from the above.
67. Skills*
    Please list your areas of highest proficiency, special skills, or other abilities that may contribute to your abilities as a participant in the Youth Employment Program.
71. PREVIOUS WORK EXPERIENCE (Please list most recent first)
73. Date
    Date Start Date

    —

    Date End Date
74. Name of Company
75. City, ST
76. Position/Title
78. Job notes, tasks performed, and reason for leaving:
80. Date
    Date Start Date

    —

    Date End Date
81. Name of Company
82. City, ST
83. Position/Title
85. Job notes, tasks performed, and reason for leaving:
87. Date
    Date Start Date

    —

    Date End Date
88. Name of Company
89. City, ST
90. Position/Title
94. Do you plan to attend college in the Fall Semester?*
    -- Select One --YesNo
96. NOTE: Please submit a copy of a form of identication verifying your Port Arthur residency.
97. Port Arthur Residency
101. CERTIFICATION:
     I certify that the information on this application and its attachments is true and correct to the best of my knowledge and that there is no intent on my part to defraud. I authorize inquires as to the validity of this information. The data may be distributed to employers and social services agencies for the purpose of obtaining training and/or employment. I understand that providing false information on this application and its attachments can result in my being declared ineligible for participation or terminated, if already enrolled, and I may be subject to prosecution under the law. I further certify that I fully understand the foregoing.
103. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
105. Applicant's Electronic Signature*
106. Date
     Date
108. Parent/Guardian's Electronic Signature (For Applicants under that age of 18 years of age)
     Signature for waiver will be required if participant is accepted into the Youth Employment Program.
109. Date
     Date
Leave This Blank:


111. 1. Receive an email copy of this form.
112. Email address

     This field is not part of the form submission.

113. Submit

* indicates a required field