Jefferson Built Application

Student APPLICATION

First Name

Last Name

Street Address

City

State

Zip

Main Phone

Secondary Phone

What School/s Attended?

How Did You Hear About Jefferson BuiLT?

Will you be 18 before June 1?

Yes No

Are You Legally Able to Work in the US?

Yes No

What is your level of Education?

Do you have relatives working for one of the sponsoring companies?

Yes No

Do you work for or have you been recruited by a sponsoring company?

Yes No

If yes to either of the above two questions, enter the sponsoring company or companies.