First Name: *
Last Name: *
Email Address: *
State:	CT
Zip: *
CTHires Username:
Veteran Status: *	Please Select Non-Veteran Served less than 180 days Served more than 180 days Eligible Spouse
Race/Ethnicity: *	Please Select Hispanic/Latino American Indian/Native Asian Black/African American Native Hawaiian/Pacific Islander White Decline to Answer
Disability Status: *	Please Select Yes No Decline to Answer
Gender: *	Please Select Male Female Declined to answer
Date of Birth: *	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
Are you unemployed or working fewer hours due to Covid-19?: *	No Yes
Unemployment Insurance status: *	Have applied for unemployment insurance in the last 4 weeks awaiting approval Have applied for unemployment insurance in the last 4 weeks and was denied Currently collecting unemployment insurance Exhausted unemployment insurance after March 2020 No longer receiving unemployment insurance due to employment None of the above
Preferred Language:	English Español (Spanish) 中文 (Chinese)
Would you like a counselor to contact you for additional assistance?	Yes No
Are you interested in courses such as Construction, Welding, Manufacturing, HVAC?	Yes No
How did you hear about SkillUp CT?: *	Please Select Social Media Radio Spotify Newspaper/Flyer Website Family/Friend Other
Other Referral Note:
I have read and understand the Metrix Learning System Policies.
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