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CCC01A - SYSP Application Form New 8.5 X 11

Applications form

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kinikinayy
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21 views

CCC01A - SYSP Application Form New 8.5 X 11

Applications form

Uploaded by

kinikinayy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CCC 01A

GOVERNMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO


SPECIALISED YOUTH SERVICE PROGRAMMES (SYSP)
FOR OFFICIAL USE ONLY
APPLICATION FORM Participant No.
Name of Authorising Officer (Block Letters):

Signature of Authorising Officer:


(01) CCC •
(02) MILAT
PHOTOGRAPH
1. Surname: First Name(s): Maiden Name: (if applicable)
Bennett Jelani

2. (a) Residential Address: (b) Postal Address (if different):


Street:__________________________________
157-158 First Street East, Recreation Street
Street: __________________________________
Village: ________________________________
Arima Old Road
Village: _________________________________
Town/City: _____________________________
Arima
Town/City: ______________________________
3. (a) Telephone (Home): -
7982119
(xxx-xxxx) (b) Telephone (Mobile): - (xxx-xxxx)

(c) Other Contact No.: - (xxx-xxxx)

4. E-Mail Address (if any): _________________________ 5.


[email protected]
Date of Birth: 17
/ 01
/ 2007
(dd/mm/yyyy)

6. Sex: Male *
Female 7. Religion: ________________________________
Non-denominational

8. Marital Status: Single *


Married Common Law
Separated Divorced Widowed

9. (a) Identification: _______________________________


20070117020
(b) National Insurance Scheme No: _______________
(Select one: ID Card No., Passport No., Drivers Permit No.)
(c) Board of Inland Revenue No: ____________________ (d) Banker: ________________________________
(e) Account No.: ____________________________

10. Description (a) Hair Colour: ____________ Brown


(b) Eye Colour: ___________
Brown
(c) Height: _________(cm)177

(d) Blood Type: ____________ (e) Ethnicity: _____________


African Descent
(f) Weight: _________(kg)
(g) Distinguishing Marks: ______________________________________________________

11.(a) Emergency Contact: ________________________


7776937
(b) Relationship: ____________________________ Grandmother

(Mother, Father, Brother, Sister, etc)


(c)Address: ___________________________________________________________________________________
Same as address above

(Street) (Village) (Town/City)

(d) Telephone (Home): - (xxx-xxxx) (e) Other Contact No.: - (xxx-xxxx)


12.(a) No. of Children: None 0
1-2 3-4 5-6 >6

(b) Children Information (Validation in the form of birth certificates must be shown)
SURNAME FIRST NAME(S) SEX DATE OF BIRTH
(Male/Female) (dd/mm/yyyy)

13. Employment (List employment over the last three (03) years, most recent first)
ORGANISATION/ COMPANY EMPLOYER START DATE END DATE POSITION INCOME
TELEPHONE (dd/mm/yyyy) (dd/mm/yyyy)

14. Education
(a) Highest Education Level Attained (this section must be completed by all applicants):
Primary Secondary Technical/Vocation Tertiary

(b) Schools Attended:


NAME ENTRY DATE EXIT DATE EXAMINATION TAKEN
(dd/mm/yyyy) (dd/mm/yyyy)
Arima New Government 01/09/2012 01/05/2019 SEA

01/09/2019 01/04/2023 None


Five Rivers Secondary

(c) Qualifications Achieved/Attained


(i) ACADEMIC
SUBJECT LEVEL (e.g. General, O, A) GRADE (e.g. A, I, II)

(ii) TECHNICAL/VOCATIONAL
COURSE AWARD (eg.Certificate, Diploma)
(iii) TERTIARY
AREA OF STUDY LEVEL (PhD, MSc, BSc, Dip)

15. Additional/Interested Areas of Study/Training (all applicants can complete; MY-PART & MILAT applicants must complete)
SUBJECTS/COURSES LEVEL/AWARD

16. Hobbies:
Music, Cooking, Hiking, Swimming

17. Membership in Social Groups (e.g. Clubs, Youth Groups, Drama Groups, Cadet Force, etc.)
ORGANISATION/GROUP DURATION POSITION(S) HELD
<6 months 6mths-2yrs >2 years

18. Sports:
Football, Swimming

19. Do you have any legal matters pending? YES NO


If “YES” please explain

No

20. Have you ever been convicted? YES NO If “YES” give details
CONVICTION DATE OF CONVICTION SENTENCE
(dd/mm/yyyy)

21. Disabilities/Illnesses/Allergies. YES NO


If “YES” please explain

No
22. Certificate of Medical Fitness
I certify that has been medically examined by me and is fit for
involvement in normal physical activities.

MEDICAL OFFICER DATE (dd/mm/yyyy)


MINISTRY OF HEALTH
Note: Not valid without an Official Stamp

23. Other Relevant Information


Have you ever been enlisted in any of the SYSPs before? YES NO
If “YES” state Programme(s) Name and dates of participation
PROGRAMME DATE

24. I certify that all the above information given by me is true, complete and correct to the best of my knowledge and
belief. I understand that any false statement or the withholding of any relevant information may hinder my
eligibility to qualify for or result in my dismissal from, any of the programmes.

SIGNATURE DATE (dd/mm/yyyy)

25. This is to certify that I, ________________________________ am the legal Parent/Guardian of


______________________________ and I give my full consent to have him/her enrolled in the
SYSP/___________ Programme for the stated period.

SIGNATURE DATE (dd/mm/yyyy)

_______________________________________________________________________________________________
The following section is to be completed if the Trainee is selected for participation in the Programme

Registration

Declaration of Acceptance of Enlistment (Temporary):


I ________________________________ hereby accept the offer of temporary enlistment in the CCC/MiLAT for
the period ________________ to ________________ or any such period as may be deemed appropriate by the
Administration of the Programme. I am prepared to accept the stipend rate of $90.00/$40.00 per day and to abide
by the rules and regulations of the Programme as laid out in the Standing Orders for the Civilian Conservation
Corps.

TRAINEE’S SIGNATURE DATE (dd/mm/yyyy)

WITNESS

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