Employe Worker Trining Agreement SECTION : GENERAL INFORMATION Orgniztion Nme: Street Aress: Authorize Contt Person: Telephone Numer: Emil Aress: Zip Coe: Fx Numer: Wesite Aress: Dte of Estlishment: Yers in Business: FT Employees: Are you urrent on ll Feerl, Stte, n Lol Txes? TAX EXEMPT Wht is the legl struture of your orgniztion? Wht is your orgniztion's primry SIC Coe? MimiDe Chek your SIC Coes here: Wht re your orgniztion's other SIC Coes? Monroe Wht is your Feerl Employer Ientifition Numer (EIN)? Lern out EINs here: EIN Wht is your Unemployment Compenstion (UC) ID? Lern out UC here: UC Wht is your Flori Sles & Use Tx (FSUT) numer? Lern out FSUT here: FSUT Plese esrie your usiness, its prouts n/or servies, n your ustomer se: Plese esrie in etil nee for trining urrent workfore: Trining Strt Dte: () Grnt Request Dollrs: (e) Totl Numer of Trinees () Your Mthing Funs: 6.97 (f) SFW Cost Per Trinee: (f = / e) () Totl Cost: () Mthing Fun %: ( = + ) ( = / ) 6.97 (g) Current Employee Averge Hourly Wge: 00.0% (h) Post Trining Averge Hourly Wge:.0.57 Will this trining vert ny lyoffs t this lotion? If, how mny? Will this trining rete ny vnies tht SFW n help fill? If, how mny? Will improve longterm wge levels of trinees Will improve shortterm wge levels of trinees Critil to longterm visiility of our orgniztion Critil to shortterm viility of our orgniztion Will help prevent orgniztion hving to relote opertions Will lower employee turnover Is your orgniztion reeiving Stte or Feerl funing for this trining request If yes Plese Explin Is this trining for Inument employees We hve ientifie 0 employees tht meet the efinition of selfsuffieny s efine y SFWIB ut will not e retine unless itionl trining or servies re reeive. CERTIFICATION BY CAREER CENTER DIRECTOR OR AUTHORIZED MANAGEMENT REPRESENTATIVE Contrt Numer Funing Soure I herey ertify tht the informtion liste ove n tthe to this pplition is true n urte. I m wre tht ny flse informtion or intene omissions my sujet me to ivil or riminl penlties for filing of flse puli reors n/or forfeiture of ny trining wr pprove through this request. NAME: TITLE: SIGNATURE: DATE: Generl informtion Pge of 4 Print te: 6/4/008 @ :5 PM
Employe Worker Trining Agreement Lst Nme First Nme Deprtment Jo Title (Current) Aur Crlos Mintnene Fility Min Teh Dir. Sme Jo Title (Post Trining) Setion : Trining Projet Detil Type of Trining Cost per trinee Limite English Nees (Yes or No) CPR/First Ai & Essentil Lerning 79. No Certifition Totl Hours Pi Durring Trining Is Employee Self Suffiient s efine y SFWIB (Yes or No) Employee(s) Current Wge Employee(s) Post Trining Wge % of Employee Fringe Benefit Employer Mth Wge & Benefits CPR Liense & Certifite of Comp. No.0.57 9% 6.97 4 5 6 7 8 9 0 4 5 6 7 8 9 0 Trining Projet Detil Pge of 4 Print te: 6/4/008 @ :4 PM
Employe Worker Trining Agreement 4 5 6 7 8 9 0 4 5 6 7 8 9 40 4 4 4 44 45 46 47 48 49 50 Totl Employees in Nee of Trining 79. Averge Wge.0.57 6.97 Trining Projet Detil Pge of 4 Print te: 6/4/008 @ :4 PM
Employe Worker Trining Agreement Ctegory SECTION : TRAINING PROGRAM BUDGET Grnt Request Employer Mth Trinee Wges & Benefits 6.97 6.97 Trining Equipment Purhse Fility Usge Cnnot Fun with Grnt 4 Trvel, Foo, & Loging Dollrs 5 Instrutor Wges/Tuition e f g 6 Curriulum Development 7 Mterils, Supplies, & Textooks e f 8 Other Cost Su Totl 9 Iniret Costs Relevnt esription TOTALS 6.97 6.97 Totl Trining Progrm Buget Pge of 4 Print te: 6/4/008 @ :4 PM
Employe Worker Trining Agreement SECTION 4: TRAINING PROVIDER INFORMATION Trining Provier Nme (): Street Aress: Authorize Contt Person Telephone Numer: Trining Desription Type of Triner: Zip Coe: Fx Numer: Trining Lotion Trining Provier Nme (): Street Aress: Type of Triner: Zip Coe: Authorize Contt Person Telephone Numer: Fx Numer: Trining Desription Trining Lotion Atth Curriulum Outline n Ientify Certifite or Creentil Reeive SECTION 5: EMPLOYER FINANCIAL VIABILITY Atth your most reent tx return, opy of your ouptionl liense, n the W9 Form. SECTION 6: CERTIFICATION BY AUTHORIZED EMPLOYER REPRESENTATIVE As n uthorize representtive of the orgniztion pplying for the "Customize Trining Awr", I herey ertify tht the informtion liste ove n tthe to this pplition is true n urte. I m wre tht ny flse informtion or intene omissions my sujet me to ivil or riminl penlties for filing of flse puli reors n/or forfeiture of ny trining wr pprove through this progrm. NAME: SIGNATURE: TITLE: DATE: Trining Provier Informtion Pge 4 of 4 Print te: 6/4/008 @ :4 PM
Employe Worker Trining Agreement SECTION 4: TRAINING PROVIDER INFORMATION Trining Provier Nme (): Street Aress: Authorize Contt Person Telephone Numer: Trining Desription Type of Triner: Zip Coe: Fx Numer: Trining Lotion Trining Provier Nme (): Street Aress: Type of Triner: Zip Coe: Authorize Contt Person Telephone Numer: Fx Numer: Trining Desription Trining Lotion Atth Curriulum Outline n Ientify Certifite or Creentil Reeive SECTION 5: EMPLOYER FINANCIAL VIABILITY Atth your most reent tx return, opy of your ouptionl liense, n the W9 Form. SECTION 6: CERTIFICATION BY AUTHORIZED EMPLOYER REPRESENTATIVE As n uthorize representtive of the orgniztion pplying for the "Customize Trining Awr", I herey ertify tht the informtion liste ove n tthe to this pplition is true n urte. I m wre tht ny flse informtion or intene omissions my sujet me to ivil or riminl penlties for filing of flse puli reors n/or forfeiture of ny trining wr pprove through this progrm. NAME: SIGNATURE: TITLE: DATE: Trining Provier Informtion Pge 4 of 4 Print te: 6/4/008 @ :5 PM