Name: / Last 4 of SSN: / DeadlineDate
/ Petition #
Address:
Phone # :
/ Email Address:
Trade Employer:
/ Job Title:
Training requested: Occupational skills Remedial Prerequisites for occupational skills On-the-Job (OJT) Customized
I request approval to participate in the training described in this application. The information I provide is correct and complete to the best of my knowledge. I understand that penalties are provided for willful misrepresentation made to obtain allowances to which I am not entitled. I understand that beginning TAA training will void my ability to receive Alternative Trade Adjustment Assistance, if otherwise eligible.
* Has worker received Trade benefits under a prior certification in the past 10 years? Yes No
Applicant signature / Date
TAA representative signature / Date
Email / Phone / Fax
JobCenter / Employment goal with O*Net Code
TO BE COMPLETED BY TRAINING FACILITY REPRESENTATIVE. Please provide the following information regarding the PROPOSED training program. The program length should be the shortest period of time needed to achieve the desired results.
Name & address of training provider (employer if OJT)
Training site if different /
Training program/course(s):
Will training lead to an AS degree Yes No If no, credential to be obtained:
Start Date End Date Total calendar weeks of training
ESTIMATE OF TRAINING COSTS
*If actual costs or dates are not known, estimate based on past practice.
Tuition / $
Books / $
Fees / $
Uniforms / $
Health Insurance / $
General Supplies(Max $30 per semester, $15 summer) / $
Other Materials (required by program) / $
SUB TOTAL / $
Less grants, non-loan financial aid, other $ / $
TOTAL COST / $
/ No. of Hours Per Day OR / MON / TUE / WED / THUR / FRI / SAT / Sun
No. of Credits Per Semester / Fall / Winter
/ Fall
/ Winter
/ Fall
/ Winter
Spring / Summer
/ Spring
/ Summer
/ Spring
/ Summer
Would the individual be participating on a full-time basis, in accordance with the training facility’s established hours and days of training? / Yes No
Are any scheduled breaks in training greater than 30 days? If yes, attach facility’s published calendar or training schedule. / Yes No
Will other vendors be involved in providing materials? If yes, identify vendor(s) and required supplies (attach list from school). / Yes No
Does the training involve distance learning? If yes, attach a list of the specific program requirements or milestones. / Yes No
CERTIFICATION: The undersigned certifies that estimates of training-related costs for training after the above start date have NOT been offset by any anticipated or received contributions from the training applicant or sources otherwise personal to the applicant, such as contributions from the applicant’s friends or relatives.
Print Name and Title /
Signature of Authorized Representative /
Date
Phone /
Fax /
TO BE COMPLETED BY LOCAL OFFICE TAA REPRESENTATIVE
/ Co-enrollment: Wagner-Peyser WIA VETSNumber of miles from worker’s residence to training site: / Method of transportation to training:
Estimated cost of transportation and subsistence allowances, if any: / Total cost of proposed training including transportation and subsistence allowances:
If contributions are expected from any other funding source(s), indicate amount below. / Subtract amount(s) at left, if any, for total cost to TAA
WIA / Employer/Industry Council / Union/Labor Organization / Other (specify):
A separate proposal must be submitted for each training provider. Attach address, phone and fax numbers for any vendor(s) involved other than the training provider. / Central Office Use Only: / Training is / approved denied / Signature and date