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2. Gateway Academy Services Request
4. First Name*
5. Last Name*
7. Date of Birth
   Date of Birth
   please enter the mm/dd/yyyy for your date of birth.
8. Email address:
9. Telephone number
11. Address1
13. City
14. State
15. Zip
17. Are you currently a Norfolk resident? *

    1. Yes
    2. No
19. Are you currently receiving SNAP benefits?*

    1. Yes
    2. No
21. Are you currently receiving TANF benefits?*

    1. Yes
    2. No
23. Are you between the age of 18-49 years old with no dependents on your SNAP case? Please answer N/A if you do not have SNAP benefits.

    1. Yes
    2. No
    3. N/A
25. Have you been convicted of multiple misdemeanor charges (at least three)?*

    1. Yes
    2. No
27. Have you ever been convicted of a felony charge?

    1. Yes
    2. No
29. Do you have a HS Diploma or GED?

    1. Yes
    2. No
31. Which training program are you interested in?

    1. Certified Customer Service Professional
    2. Certified Medical Assistant (CCMA)
    3. Certified Nursing Assistant
    4. Commercial Drivers License
    5. CompTIA A+
    6. Medical Administrative Assistant (MAA)
    7. Medical Billing & Coding
    8. Phlebotomy Technician
    9. ServSafe Food Protection Manager
    10. Skilled Trades - Welding, Plumbing, Carpentry
33. Additional comments
35. How did you hear about us?
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field