Yankton Sioux Tribe

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Marital Status *

Single

Married

Divorced

Separated

Widowed

Education Level *

Elementary/Middle School

High School

College/University

Career Training/Occupational Certifications

Please rate your attendance during the course of your education career: *

Poor

Fair

Good

Do you have dependents under the age of 18 y/o? (If yes, please answer the next question? *

Yes

No

Do you have reliable child care?

Yes

No

Do you have a valid South Dakota Drivers License? If yes, please provide YST-WIOA a copy. *

Yes

No

Have you served with the armed services? *

If yes, please provide credentials. For Males over the age of 18 years old, please list your selective service number.

Yes

No

I authorize such investigation of any information requested by the Yankton Sioux Tribe-WIOA program. *

Yes

No

I release from liability any person giving or receiving any such information. I understand that falsification of data received or other derogatory information discovered as a result of this investigation may prevent me being hired, or if hired, may subject me to immediate dismissal. In the event of employment, I understand that also or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. I certify that, to the best of my knowledge and believe, all my statements are true, correct, complete, and made in good faith. *

Yes

No

Signature Date *

MM

DD

YYYY

Signature Date *

MM

DD

YYYY