Durham Work Opportunity and Readiness for Career Seminar
Dates: February 16-20
Time: 10 a.m. – 4:30 p.m
Location: Durham Human Services Building, 414 East Main Street, Conference Room A

Participant Application
1. Basic Information
Name: _____________________________________________ Age: ______ Date of Birth: _________________
Street Address: ____________________________________________ City: ________________ Zip: _________
Phone number: ___________________________________E-mail: ____________________________________
School: ___________________________________________________ Highest grade completed: ____________
2. Parent/Guardian Information (if under 18)
Parent/Guardian name: ________________________________________ Relationship: __________________
Street Address: _____________________________________________ City: _______________ Zip: ________
Phone number: _______________________________________
3. What jobs, if any, have you had in the past?
A. Employer: ___________________________________________ Job Title: _______________________

How long did you work there? _________________ Job duties: _______________________________

B. Employer: __________________________________________ Job Title: ________________________

How long did you work there? _________________ Job duties: ________________________________

4. Are you currently on probation/parole? Yes □ No □ If yes: Juvenile □ Adult □
Name of Probation Officer: ________________________________________________
5. What special skills do you have (including any computer skills)?

7. Why do you want to participate in the D-WORC Seminar?

To submit this participant application:
E-mail form to: ajeffries@dconc.gov
Fax to: 919-560-0530
Deliver to: Project BUILD, 721 Foster Street, Durham, NC 27701

Any questions? Call 919.560.0537