EMPLOYER DATA FORM:

ON-THE-JOB TRAINING/CUSTOMIZED TRAINING PRE-AWARD

Thank you for your interest in the O‘ahu WorkLinks On-the-Job Training (OJT) and/or Customized Training (CT) programs. As a prospective business partner, please provide the following information necessary to qualify you for the Workforce Investment Act (WIA), National Emergency Grant, and State Energy Sector Program Federal Funds. Fill in all blanks. If items do not apply, mark them N/A.Please fax completed form to , .

Date:

Name(s) under which the company does business (also show predecessors and successors in interest, if any):

Name:
Street Address: / City: / HI / Zip:
Have you been at this business address for at least 120 days? / Y N / If no, did the relocation result in any layoffs? / Y N
Phone: / Fax: / Website:
Principal’s Name: / Position:
Contact Person: / Position:
Phone: / Fax: / Email:
Ownership Type:
Nature of Business/Industry: / Federal I.D.#:
Taxpayer ID # (GET): / W / Unemployment Insurance #:
Workers Compensation Policy #: / # of Years in Business:
Commercial General Liability #: / Temporary Disability Insurance #:
Medical Benefits Carrier: / Medical Policy #:
Other Benefits:
Number of Employees: / Ratio of Supervisor to Employees:
OJT Supervisor Years of Industry Experience: / OJT Supervisor Years of Supervisory Experience:
Describe working environment:
Equipment OJT Position will use:
Written Safety Policies/Procedures/Training / Y N / OSHA Compliant? / Y N
Written Policy & Grounds for Termination / Y N / Written Grievance Policy: / Y N
Do you maintain personnel records? / Y N / Are you in good financial standing?: (Your Financial Statement and/or Annual Report must be available for review.) / Y N

Please check the documents available for review:

Y N / Company By-Laws / Y N / Articles of Incorporation / Y N / Financial Statement
Y N / Organizational Chart / Y N / Annual Report / Y N / Company Brochure
Y N / Participant Personnel Records
Who maintains your payroll system? / Phone:

Do you have the following payroll systems items? If no, please comment:

  • Copies of time sheets or other forms of attendance records
/ Y N
  • Do you maintain a general payroll ledger?
/ Y N
  • Do you have receipts or records showing federal and state taxes paid?
/ Y N
  • Are the proposed OJT positions covered under collective bargaining?
/ Y N

(If the proposed OJT activity would be inconsistent with a collective bargaining agreement, both
you and the labor organization must provide written concurrence before the activity begins.)

Will the OJT activity result in a currently employed worker being laid off or having a reduction in the hours of non-overtime work, wages, or benefits? / Y N
Has any other individual been laid off from the same or substantially equivalent job as the OJT position? / Y N
Is the OJT job being created in a promotional line that infringes in any way on the promotional opportunities of currently employed workers? / Y N
Is assistance with OJT being sought in connection with past or impending job losses at other facilities? / Y N
Have any Worker Assistant and Retraining Notifications relating to the company been filed? / Y N

Statement and Signature: I certify that the information provided above is accurate to the best of my knowledge.

Signature:
Name:
Title:
Phone:
Date:

Revised 03/31/2011Page 1 of 2