APPLICANT REGISTRATION FORM     (DES-511)

You may submit the requested registration to the Tennessee Department of Labor and Workforce Development/Tennessee Career Center by:

1. Visiting - 1610 University Ave - Knoxville TN 37921

2. Mailing Address – 1610 University Ave, Suite 106-Knoxville, TN 37921

3. Package Service - 1610 University Ave, Suite 106 - Knoxville TN 37921

4. FAX information to 865-594-6266 (use form below). Please do not email the below form.

5. Internet registration:  https://ecmats.tn.gov/eCMATS/

To FAX registration:

PLEASE COPY AND PRINT THE BELOW (2 PAGE) FORM - COMPLETE ALL AREAS OF INFORMATION AND FAX TO: 865-594-6266

Registration Form

Registration Date __________________                   Social Security Number: ________---_____---__________

Office Use Only       LWIA: _________      LOFF: _________   Occup code _________________exp. _____ Occup code _________________exp. _____ Occup code _________________exp. _____

Check all that apply and fill in blanks when applicable.  Please PRINT.

Name: _____________________________________________________

                                              (Last, First, Middle Initial)

Date of Birth: (Month-Day-Year) ____--___--_____    Gender/sex:  male

                                                                                                             female

Email Address: ___________________________

Telephone number/s: Home:  (______) ______-_________ Work:   (______) _______-________ Cell:     (______) _______-________

Primary Address:  Home   Work   Other

(Street, Apt. #, PO Box) __________________________________________
City ___________________ State _____ Zip _________ County _________

Additional Address:  Home   Work   Other

(Street, Apt. #, PO Box) __________________________________________

City ___________________ State _____ Zip _________ County _________

Secondary Contact Person/Information:                                                                Are you a U.S. Citizen:   Yes    No

Name:  _______________________________________________________         You will be required to provide identi-                                                                          

(Street, Apt. #, PO Box) __________________________________________         fication and evidence of employment

City ___________________ State _____ Zip _________ County _________          eligibility.

Telephone Number:____________________ Email: ___________________         

                                                                                                                                     If you were born after January 1, 1960

 Employment Status:  employed;  unemployed                                                 please provide your Selective Service                                                                                                                                                                           

                                                                                                                                     Number. _________________________

Education: In-school, Not In-school;    Highest Grade Completed: _____ (numbers of years)

Achieved Post Secondary Degree or Certificate:   Yes   No,   If yes Degree/Certificate Type: ________________________  School/Institution Name:  _________________________  Course Name: ___________________ Date Completed:__________