Kimberly.Elrobi806@gmail.com

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Enrollment Form

Application Form

East Lubbock Resident Owned Business Initiative Application Form

**Please note all fields are required to be filled. Use NA for items that do not apply to you.

Before submission of application you MUST have on hand ALL 4 physical documents listed:

Valid State Driver License/Identification Card
Social Security Card
Birth Certificate
Diploma/Official Transcript/GED

East Lubbock Resident Owned Business Initiative Enrollment Form

Date of Birth:

First Name:

M.I:

Last Name:

Todays Date:

Free Text

Address:

Street Address:

Apartment #:

City:

State:

Zip Code:

Phone:

Email:

Date Available:

Social Security No.:

Race:

Are you a citizen of the United States?

Yes

No

If no, are you authorized to work in the U.S.?

Yes

No

Have you ever been convicted of a felony?

Yes

No

DISCLAIMER

DISCLAIMER

* A Felony Does Not Disqualify You

If yes, explain:

EDUCATION

EDUCATION

Level of Education:

GED

Some High School

High School Graduate

Some College

College Graduate

Trade School

If Yes, which trade?

Income

INCOME

Household Size:

Total Household Income:

REFERENCES

PROFESSIONAL REFERENCES ONLY:

Reference 1:

Professional Reference #1

Full Name:

Relationship:

Company:

Address:

Phone Number:

Reference 2:

Professional Reference #2

Full Name:

Relationship:

Company:

Address:

Phone Number:

Reference 3:

Professional Reference #3

Full Name:

Relationship:

Company:

Address:

Phone Number:

Previous Employment

PREVIOUS EMPLOYMENT

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary $:

End Salary $:

Responsibilities:

Start Date:

End Date:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

No

Previous Employment:

PREVIOUS EMPLOYMENT

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary $:

End Salary $:

Responsibilities:

Start Date:

End Date:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

No

Previous Employment:

PREVIOUS EMPLOYMENT

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary $:

End Salary $:

Responsibilities:

Start Date:

End Date:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes

No

Military Service:

MILITARY SERVICE

Branch:

Start Year:

End Year:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

Do you have any disabilities if so please explain :

Disclaimer and Signature:

DISCLAIMER AND SIGNATURE

Free Text

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature:

Date:

Thank you for submitting your enrollment form. We will get back to you as soon as possible.

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Contact Information

Reggie Dial - Founder / Executive Director

Phone: 806 500 3476

Email: elrobi806@gmail.com

Kimberly Brown - Program Director

Phone: 806.782.8667

Email: Kimberly.Elrobi806@gmail.com

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All Rights Reserved | EL ROBI

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