Eligible Training Provider Application

ELIGIBLE TRAINING PROVIDER APPLICATION

Provider/Institution Name (Legal Name and/or Business Name): Click here to enter text.

Main Address:

Street Address: Click here to enter text.
Street Address Line 2: Click here to enter text.
City: Click here to enter text. / State: Click here to enter text. / Zip Code: Click here to enter text.
Mailing Address (if different than above address): Click here to enter text.
Main Phone #: Click here to enter text. / Main Fax #: Click here to enter text.
Institution URL: () Click here to enter text.
Federal Identification Number (FEIN): Click here to enter text.

Billing Address (if different)

Street Address: Click here to enter text.
Street Address Line 2: Click here to enter text.
City: Click here to enter text. / State: Click here to enter text. / Zip Code: Click here to enter text.

Authorized ETPL Contact Person

Contact Name: Click here to enter text. / Contact Title: Click here to enter text.
Contact Phone #: Click here to enter text. / Contact Fax #: Click here to enter text. / Contact Email: Click here to enter text.

Status of Organization

Institution is applying for eligibility under which one of the following:
☐HEA Funding Title IV ☐Registered Apprenticeship ☐Other Public or Private Organization
Institution Type (select one):
☐Four-year College or University ☐Secondary Schools/Career & Technical Education
☐Two-year Technical/Community College ☐Community Based Organization
☐Registered Apprenticeship Programs ☐Trade Association
☐Other, Please specify: Click here to enter text.
Institution Ownership:
☐Private, For Profit ☐Private, Not-for-Profit ☐Public

The following questions are meant to determine your organization’s ability to sustain your programs in good standing during the initial eligibility period:

Number of years in business as a training provider: Click here to enter text.
Are you registered with the Secretary of State? ☐Yes ☐No
Is your organization/institution ADA compliant? ☐Yes ☐No
Are all of your training facilities ADA compliant? ☐Yes ☐No
This includes physical accessibility, programmatic accessibility, and communications.
Are you in good standing with the Division of Taxation? ☐Yes ☐No
Are you an accredited institution? ☐Yes ☐No
If yes, indicate accrediting agency: Click here to enter text.
If no, please provide brief description of your credentials:Click here to enter text.
How often must you recertify for your credential? Click here to enter text.
When is your next recertification due? MM/DD/YYY Click here to enter text.
Please provide a brief description of your institution:Click here to enter text.
Please describe job placement methods used to assist graduates in obtaining employment and any partnerships you may have: (please limit your response to 500 characters) Click here to enter text.
Physical Training Sites: Please indicate the address to each training facility
1.
Facility Name: Click here to enter text.
Street Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Special Notes/Comments: Click here to enter text. / 2.
Facility Name: Click here to enter text.
Street Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Special Notes/Comments: Click here to enter text.
3.
Facility Name: Click here to enter text.
Street Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Special Notes/Comments: Click here to enter text. / 4.
Facility Name: Click here to enter text.
Street Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Special Notes/Comments: Click here to enter text.
5.
Facility Name: Click here to enter text.
Street Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Special Notes/Comments: Click here to enter text. / 6.
Facility Name: Click here to enter text.
Street Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Special Notes/Comments: Click here to enter text.

☐ I certify that I am an authorized representative of the applicant institution seeking eligibility for the Eligible Training Provider List.

☐I acknowledge that initial eligibility will be granted to each program for a 12-month period if approved. After the initial period of eligibility, each eligible program is subject to continuing eligibility requirements.

☐I understand that applicant institutions will be subject to review for compliance with applicable state and federal laws.

Person completing this form:

Printed Name: Click here to enter text.

Title: Click here to enter text.

The completed application and supporting documentation can be emailed to:

Kristen Taft @ or mailed to the below address:

Kristen Taft

Workforce Development Services Division

RI Department of Labor & Training

1511 Pontiac Ave Bld 73 FL 3

Cranston, RI 02920

DLT is an equal opportunity employer/program – auxiliary aids and services available upon request. TTY via RI Relay: 711 Page 1 of 3