PRE-APPLICATION
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WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA)

PRE-APPLICATION

For entities intending to apply for Eligible Training Provider status and the Eligible Training Provider List initial eligibility: one year approval
Name of Training Provider*
Entity Name
Legal Name
Connecticut UI Tax Registration Number
Federal Employment Identification Number (FEIN)
Contact Person
Name / Title
Address
City / State / Zip
Internet Address
Phone: / Fax:
E-mail:
*If the entity is a sole proprietorship or general partnership and the name entered on the “Name of Training Provider” line is different from the entity’s legal name, a copy of the entity’s “doing business as” (DBA) filing with the town clerk in the municipality in which the entity is based must be submitted with the completed Pre-Application.
Please submit thecompleted original Pre-Application to the LeadBoard and a copy to any applicable Secondary Board(s) as indicated by your completionof items 1 and 2 onthe next page.

Revised 7/1/15

PRE-APPLICATION
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PRE-APPLICATION
The purpose of the Pre-Application is to gain an overview of the entity and its program information so the appropriate full application can be sent to you for completion. Once your Pre-Application is determined to be complete, you will receive a full application. Incomplete Pre-Applications will be returned.

PLEASE COMPLETE ALL SECTIONS THAT APPLY TO YOUR ENTITY AND PROGRAMS

SECTION 1 – ENTITY INFORMATION

Check the category that applies:
Apprenticeship Program - registered with the Connecticut Department of Labor (CTDOL)
Community Based Organization - Church
Community Based Organization - Non-Profit
Community College
Private College/University
Post-secondary Career School (former category: Private Occupational School)
(includes hospital-based, hairdresser/barber, and occupational schools)
Regional Educational Service Center
Regional Vocational-Technical School (high school)
CT State Department of Education or Adult Education
State University/College
Other (specify)
If you are currently licensed or approved by a state agency to operate in the State of Connecticut, please check all that apply and attach a copy of the license/approval letter to the completed Pre-Application:
Connecticut Office of Higher Education
Connecticut Department of Education
Title IV Eligible - Federal Financial Aid
Department of Public Health (Cosmetology/Hairdresser/Barber School if non-Title IV Eligible – Federal Financial Aid)
Included at the back of this Pre-Application is a list of Connecticut municipalities and the five Workforce Development Boards designated for those municipalities. Please indicate below: 1. The Board for the area in which your administrative office or main campus is located, and 2. The Board for the area(s) in which your programs are located, if they are in different locations than within the Lead Board’s area.
1. LeadWorkforce Development Board
2. Secondary Workforce Development Board(s)
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If you apply to be an Eligible Training Provider, you will be required to complete a full application. Please be advised that the full application will require detailed provider and program information, including, but not limited to, the following:
A. Core program information:
Description of program / Contact person(s) (Admissions and Administrative)
Number of hours of program / Curriculum design/outline
Cost of program (tuition, fees, books) / Credential/certificate/license attained
Student-teacher ratio / Location(s) of program and access (i.e., bus line)
Instructors' qualifications / ADA compliance
Schedule or calendar / Support services provided (tutor, advisor, etc.)
Admission requirements / Refund policy (attach copy of enrollment agreement)
Equipment needed for program / Financial Aid, if applicable
B. Agreement that your entity’s ETPL approval is contingent upon meeting the state minimum criteria for performance, pursuant to the requirements of the Workforce Innovation and Opportunity Act. Such criteria will includeprogram completion rates, entered employment/placement rates, placement wages, and any other performance indicators established by CTDOL. Eligible training providers will be required to report to CTDOL, in the format prescribed by CTDOL, all applicable program performance and cost information for ALL individuals enrolled in a program, for the periods prescribed by CTDOL, which periods will also include some quarters following program exit. This performance data will be made available to the public on-line at CTDOL’s ETPL website in accordance with federal and statelaw.
C. Agreement to release all student information for relevant placement and past performance in other areas.
D. Is your organization currently debarred, suspended or otherwise prohibited from doing business with the State of Connecticut or the federal government? Yes No
E. Applicant organizations will be subject to review for compliance with applicable federal and statelaws. Attach a completed, signed “Employer Authorization For the Release Of Confidential Data” form to this Pre-Application. The form is available at .
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Any misrepresentation of information on the Pre-Application or full application will be grounds for your entity’s disqualification to participate as a training provider under the Workforce Innovation and Opportunity Act.
Signature of Authorized Representative / Date
Printed name of Authorized Representative Title
Legal Name of Entity(as it appears on page 1)

BOARD USE ONLY

APPLICATION A
APPLICATION B
Date Received:
Date Full Application Mailed to Provider:
PRE-APPLICATION
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Connecticut Municipalities by WIOA Workforce Development Board (WDB) Area

WIOA 1
Southwest
Send ETPL
application to:
The WorkPlace, Inc.
350 Fairfield Ave.
Bridgeport, CT 06604 / WIOA 2
North Central
Send ETPL
application to:
Capital Workforce Partners
One Union Place
Hartford, CT 06103 / WIOA 3
Northwest
Send ETPL
application to:
Workforce Connection
249 Thomaston Ave.
Waterbury, CT 06702 / WIOA 4
Eastern
Send ETPL
application to:
Eastern Connecticut Workforce Investment Board
108 New Park Ave.
Franklin, CT 06254 / WIOA 5
South Central
Send ETPL
application to:
Workforce Alliance
560 Ella T. Grasso Blvd.
New Haven, CT 06519
Ansonia
Beacon Falls
Bridgeport
Darien
Derby
Easton
Fairfield
Greenwich
Monroe
New Canaan
Norwalk
Oxford
Seymour
Shelton
Stamford
Stratford
Trumbull
Weston
Westport
Wilton / Andover
Avon
Berlin
Bloomfield
Bolton
Bristol
Burlington
Canton
East Granby
East Hartford
East Windsor
Ellington
Enfield
Farmington
Glastonbury
Granby
Hartford
Hebron
Manchester
Marlborough
New Britain
Newington
Plainville
Plymouth
Rocky Hill
Simsbury
Somers
Southington
South Windsor
Stafford
Suffield
Tolland
Vernon
West Hartford
Wethersfield
Windsor
Windsor Locks / Barkhamsted
Bethel
Bethlehem
Bridgewater
Brookfield
Canaan
Cheshire
Colebrook
Cornwall
Danbury
Goshen
Hartland
Harwinton
Kent
Litchfield
Middlebury
Morris
Naugatuck
New Fairfield
New Hartford
New Milford
Newtown
Norfolk
North Canaan
Prospect
Redding
Ridgefield
Roxbury
Salisbury
Sharon
Sherman
Southbury
Thomaston
Torrington
Warren
Washington
Waterbury
Watertown
Winchester
Wolcott
Woodbury / Ashford
Bozrah
Brooklyn
Canterbury
Chaplin
Colchester
Columbia
Coventry
Eastford
East Lyme
Franklin
Griswold
Groton
Hampton
Killingly
Lebanon
Ledyard
Lisbon
Lyme
Mansfield
Montville
New London
North Stonington
Norwich
Old Lyme
Plainfield
Pomfret
Preston
Putnam
Salem
Scotland
Sprague
Sterling
Stonington
Thompson
Union
Voluntown
Waterford
Willington
Windham
Woodstock / Bethany
Branford
Chester
Clinton
Cromwell
Deep River
Durham
East Haddam
East Hampton
East Haven
Essex
Guilford
Haddam
Hamden
Killingworth
Madison
Meriden
Middlefield
Middletown
Milford
New Haven
North Branford
North Haven
Old Saybrook
Orange
Portland
Wallingford
Westbrook
West Haven
Woodbridge