ETI Apprenticeship Application

Notice: Applicants will be prompted to submit all required documentation at the end of the application.
No application will be accepted without all of the required documentation for the program the applicant is
applying to.

Applicants will be required to provide all original documents (including sealed official transcripts - if
applicable) when invited to attend boot camp prior to acceptance to the apprenticeship. For a list of all
required documents, visit the Information for Applicants tab on the ETI website and refer to the
appropriate program button.

Applicant Information
Application Tutorial:

We highly recommend that all applicants watch the video linked below BEFORE submitting an application. This video will
help prepare applicants for what will be asked for on the application, and hopefully answer questions before they arise.

ETI Application Tutorial

Applicant Information

Applicant Type: * Transportation Systems Apprentice

First Name: * Kevin

Last Name: * Mireles

Middle Initial:

Date of Birth: * Enter as shown

09/01/1982
Ex: MM/DD/YYYY

Address Line 1: * 2151 San Francisco ave

Address Line 2:

City: * Long beach

State: * Ca

Zip Code: * 90806

Note: the ETI utilizes email as the primary form of communication. Therefore, it is extremely important that the
ETI has the correct email address on file for you. It is your responsibility to notify the ETI if you change your
email address.

Email Address: * [email protected]

Verify Email [email protected]

Address: *
Phones

By providing your cell phone carrier, you are opting to receive text message notifications from the ETI. If you do not wish to
receive updates via text message, you should not provide your cell phone carrier. If your cell carrier is not listed in the
dropdown list, text notifications will not be available to you at this time. Feel free to input your cell carrier's name in the
"unsupported carrier" field and we will notify you if this feature becomes available.

Home Phone: 5625918275

Cell Phone: * 5623058467

Cell Carrier: T-Mobile, Mint Mobile, Or Ting (Gsm Devices)

How did you become ETI Website

aware of this
apprenticeship
opportunity? *

Emergency Contact

Contact Name: * Irma mireles

Contact Address: 2151 San Francisco ave

Contact Phone: * 5626823794

Education

Education

Highest Year of 4 Or More Years Of College

Education
Completed: *

Can you provide Long Beach City College

evidence that you
have completed
training with any of
the following?

High School(s): * Millikan high school

College(s) or Long Beach city college

Vocational School(s)

California state university of Long Beach

Background

Background

Do you have a valid Yes

Government Issued
Photo ID? *

Confirm the B9466344

Identification Number
from the Government
Issued ID Provided: *

Do you have any Yes

electrical / electronic
experience? *

Have you applied Yes

with this
apprenticeship
program before? *

If YES, how many 2

times?

Have you participated No

in an apprenticeship
of any kind? *

Did you complete any No

school-to-career
program? *

Have you ever served No

in the US military? *

Interest & Ability

Are you available to Yes

work full-time? *

List the reason(s) Career advancement, job security, personal interest, and health
why you are applying benefits.
for this
apprenticeship
program: *

Are you physically Yes

and mentally able to
safely perform or
learn to safely
perform the work of
this trade, either with
or without reasonable
accommodations? *
Are you able to get to Yes
and from work at
various job sites
anywhere within the
geographical area
this apprenticeship
program covers? *

Are you able and Yes

willing to attend all
related classroom
training required? *

Are you able to climb Yes

and work from
ladders, scaffolds,
poles or towers or
various heights with
or without reasonable
accommodations? *

Can you crawl and Yes

work in confined
spaces such as
attics, manholes and
crawl spaces with or
without reasonable
accommodations? *

Are you available to Yes

work during any
shift? *

Are you able to hear Yes

and understand
verbal and written
instructions and
warnings given in
English? *
Employment History

Employment History

1. Company Name: * Macys inc

Address: * 21600 Hawthorne blvd

Torrance ca 90503

Phone Number: * 3103708511

Name of Anna
Supervisor: *

Employed From 01/2021

(mm/yyyy): *

Employed To 09/2023
(mm/yyyy): *

State your Job Title Customer Service Associate- returns, purchases, inventory, online
and Describe your orders
Work: *

Reason for Leaving: * Personal Reasons

____________________________________________________________________________________________

2. Company Name: All-Tek Electrical Services

Address: 1209 Manhattan ave

Mahayana beach ca 90266

Phone Number: 3104222668

Name of Supervisor: Brian

Employed From 12/2019

(mm/yyyy):

Employed To 12/2020
(mm/yyyy):

State your Job Title Electrical Technician- installation and maintenance or residential
and Describe your electrical systems
Work:

Reason for Leaving: Company bankruptcy

____________________________________________________________________________________________

3. Company Name: Long Beach city College

Address: 1305 E. Pacific coast highway

Long Beach ca 90806

Phone Number: 5629384528

Name of Supervisor: Sean

Employed From 01/2016
(mm/yyyy):

Employed To 09/2019
(mm/yyyy):

State your Job Title Electrical Embedded tutor- 1-1 tutoring and group facilitation of
and Describe your electrical concepts and procedures
Work:

Reason for Leaving: Covid-19

Number of Years You 3 But Less Than 4 Years

Have Been Employed
in Any Occupation
Full-Time to Date
(Except for Military
Service): *
EEOC Supplemental Information

EEOC Supplemental Information

EQUAL OPPORTUNITY PLEDGE

The ETI will not discriminate against apprenticeship applicants or apprentices based on race, religious creed (including
religious dress and grooming), color, national origin, ancestry, physical disability, mental disability (including cognitive
disability), medical condition, genetic information, marital status, sex (including pregnancy, childbirth, and medical
conditions related to pregnancy, childbirth, or breastfeeding), sexual orientation, sex stereotype, gender, gender identity,
gender expression, age 40 or older, and military and veteran status. The ETI will take affirmative action to provide equal
opportunity in apprenticeship and will operate, conduct, and administer this apprenticeship program as required under Title
29 of the Code of Federal Regulations, part 30, and the equal opportunity regulations of the State of California.

YOUR RIGHT TO EQUAL OPPORTUNITY

It is against the law for a sponsor of an apprenticeship program registered for Federal purposes to discriminate or retaliate
against, or harass, an apprenticeship applicant or apprentice based on race, color, religion, national origin, sex, sexual
orientation, age (40 years or older), genetic information, or disability. The sponsor must ensure equal opportunity with
regard to all terms, conditions, and privileges associated with apprenticeship.

FILING A DISCRIMINATION COMPLAINT: If you think you have been subjected to such discrimination, harassment, or
retaliation, you may file a complaint: a) within 300 days from the date of the alleged discrimination, harassment, retaliation,
or failure to follow the equal opportunity standards with the U.S. Department of Labor, Office of Apprenticeship, 200
Constitution Avenue, NW, Washington, DC 20210, Attn: Apprenticeship EEO Complaints, Anthony Ridgeway, (202) 693-
3536, [email protected]; or b) within 180 days from the date of the alleged discrimination,
harassment, retaliation, or failure to follow the equal opportunity standards with the State of California, Division of
Apprenticeship Standards, Administrator of Apprenticeship, Department of Industrial Relations, 1515 Clay Street, Oakland,
CA 94612. You may also be able to file complaints directly with the U.S. Equal Employment Opportunity Commission
(EEOC) or the California Department of Fair Employment and Housing (DFEH) within the time periods set by those
agencies. Their contact information is as follows: c) EEOC: 1-800-669-4000 (toll-free) or 1-800-669-6820 (toll-free TTY
number for individuals with hearing impairments). EEOC field office information is available at www.eeoc.gov or in most
telephone directories in the U.S. Government or Federal Government section, Additional information about EEOC,
including information about charge filing, is available at www.eeoc.gov; and d) DFEH: (800) 884-1684; TTY (800) 700-
2320; videophone for the hearing impaired (916) 226-5285; email [email protected], or www.dfeh.ca.gov.

Each complaint filed must be made in writing and include the following information:

1. Complainant's name, address and telephone number, or other means for contacting the complainant;
2. The identity of the respondent (i.e. the name, address, and telephone number of the individual or entity that the
complainant alleges is responsible for the discrimination);
3. A short description of the events that the complainant believes were discriminatory, harassing, or retaliatory,
including, but not limited to, when the events took place, what occurred, and why the complainant believes the
actions were discriminatory, harassing, or retaliatory (for example, because of his/her race, color, religion, sex,
sexual orientation, national origin, age (40 or older), genetic information, or disability); and
4. The complainant's signature or the signature of the complainant's authorized representative.

___________________________________

The information voluntarily provided below is simply for equal employment opportunity purposes. This information will
assist us in our efforts to provide accurate information in compliance with federal, state, and local Equal Employment
Opportunity regulations and requirements.

____________________________________________________________________________________________

Ethnic or Race Hispanic

Derivation: *

____________________________________________________________________________________________
Gender: * Male

Number of 1
Dependents: *
Voluntary Disability Disclosure

Voluntary Disability Disclosure

Please choose one of NO, I DON'T HAVE A DISABILITY

the listed options: *

Why are you being asked to complete this form?

Because we are a sponsor of a registered apprenticeship program and participate in the National Registered
Apprenticeship System that is regulated by the U.S. Department of Labor, we must reach out to, enroll, and provide equal
opportunity in apprenticeship to qualified people with disabilities. [1]To help us learn how well we are doing, we are asking
you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you
will choose to fill it out. If you are applying for apprenticeship, any answer you give will be kept private and will not be used
against you in any way.

If you already are an apprentice within our registered apprenticeship program, your answer will not be used against you in
any way. Because a person may become disabled at any time, we are required to ask all of our apprentices at the time of
enrollment, and then remind them yearly, that they may update their information. You may voluntarily self-identify as
having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially
limits a major life activity, or if you have a history of such an impairment or medical condition. Disabilities include, but are
not limited to: blindness, deafness, cancer, diabetes, epilepsy, autism, cerebral palsy, HIV/AIDS, schizophrenia, muscular
dystrophy, bipolar disorder, major depression, multiple sclerosis (MS), missing limbs or partially missing limbs, post-
traumatic stress disorder (PTSD), obsessive compulsive disorder, impairments requiring the use of a wheelchair,
intellectual disability (previously called mental retardation).

_________________

[1] Part 30 - Equal Employment Opportunity in Apprenticeship. For more information about this form or the equal
employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Apprenticeship website at
https://www.doleta.gov/OA/eeo/.
Statements of Understanding

Statements of Understanding

You must check ALL A. I am aware that it is my responsibility to keep this program informed of any change
the Boxes. If you in my address, email address, and phone number.
need clarification on B. I have read and understand the basic qualifications for entry into this program.
any item contact C. I understand that I must furnish documentation to provide evidence that I do meet
ETI: * the qualifications required for entry into the pool of eligible candidates for this
apprenticeship.
D. I understand that it is my responsibility to see that all OFFICIAL transcripts and
other required documents are provided in a timely manner in order to complete my
application.
E. I understand that if I fail to submit ALL of the required information within the
specified time frame, my application may be considered incomplete.
F. I understand that I cannot qualify for interview until I have met the minimum basic
qualifications and have provided the necessary transcripts and documents as required.
G. I hereby acknowledge that I bear the sole responsibility for completing my
application following the instructions provided.
H. I understand that interviews for qualified applicants will be scheduled in the order in
which the applications are completed.
I. I understand that any intentional false statement or information that I provide on this
application form or on other documents shall be cause for denial of oral interview or
termination of indenture, should I be selected for the program.
J. I understand that an incomplete or unsigned application form will NOT be
processed.
K. I understand that if selected, I will be required to complete the selection process by
qualifying on any examination, including a physical examination or drug testing, if
required by the sponsor; either before or after signing an indenture.
L. I have the legal right to work in the United States of America.

___________________________________

I have checked all the above (A thru L) to indicate my understanding, and state that, to the best of my knowledge,
all information provided on this form is true and accurate. I hereby grant permission to all former employers and
references listed to disclose any information concerning my past employment and/or qualifications. I agree that
any false statements made by me in this application shall constitute grounds for disqualification of my selection
or grounds for my discharge, if false information is discovered after being selected for apprenticeship.

I hereby apply for an apprenticeship indenture with this sponsor and agree that if selected, I will abide by all
Standards, Rules and Policies covered by the Indenture (Apprenticeship Agreement).

___________________________________

Please provide your firstname and lastname between two forward

slash "/" symbols in order to indicate your agreement to these terms.
(Examples: /firstname lastname/, /John Doe/)
Digital Signature: * /Kevin Mireles/

Date of Digital 7/8/2024

Signature:
Required Documentation Upload

Required Documentation Upload

All documents must be color copies that are clear and legible. All illegible documents will be rejected and will not be
considered. NOTE: You will need to keep original/sealed copies of your documents to provide if you are invited to attend
the pre-apprenticeship boot camp.

Intelligent Transportation Systems

Required Documents:

1. Valid Government Issued Photo ID (All applicants must be minimum of 18 years of age at the time of
application)
2. Original High School Diploma, GED, or college degree (Please note: any foreign high school diploma, college
degree, or transcript must be translated and notarized by a California notary. Make sure when uploading your
documents, you upload the original and the translated notarized copy.)
3. A valid social security number must be provided at the time of your indenture as an apprentice. Without a
valid social security number, we cannot register you as an apprentice with the State of California. As a result, you
will not be able to continue with the apprenticeship program.
4. Current DMV print-out showing 1 point or less.
5. Veterans may bring a copy of their DD-214 Member-4 Form

Note: Basic Algebra Math Skills are used extensively in the related classroom instruction, and highly
recommended for each applicant.

Have you ever been Yes No

known by another
name? *

Additional Long Beach City College - Electronics Technologies Program

Certifications: * Note: You will be required to upload copies of your certificates or transcripts for the option
chosen

Long Beach City IMG_0005.jpeg 3.16MB

College Certificate
Upload:

Are you a veteran No

submitting veteran- BE ADVISED: You will need to keep a copy of your DD214 as it will be required later in the
related application process
documentation? *

Valid Government IMG_0009.jpeg 1.2MB

Issued Photo ID: *

Original High School IMG_0005.jpeg 3.16MB

Diploma, GED, or
IMG_0006.jpeg 3.43MB
college degree: *
IMG_0007.jpeg 4.14MB
e.g. proof of high school completion, transcripts, etc.