EMPLOYER APPLICATION
Is the business owner or the trainee’s direct supervisor a member of the trainee’s immediate family? (wife, husband, son, daughter, mother, father, sister, brother, in-laws, stepparent or stepchild, or significant other) / □ Yes □ No
Is the OJT position(s) starting hourly rate below $10.00 per hour? / □ Yes □ No
Is the OJT position(s) paid solely based on commission, tips, piece work or incentives? / □ Yes □ No
Does this position offer less than 32 hours per week? / □ Yes □ No
Is this job expected to last less than a year in the normal course of business? / □ Yes □ No
Has the trainee (employee) already started working for your company? / □ Yes □ No
Will the OJT position(s) be part of a staffing or hiring agency contract? / □ Yes □ No
If you marked yes to any of these previous 7 questions, please contact OhioMeansJobs-Wayne County before completing Step 2.
Company Name: / Business Phone:
Address: / Fax:
City/State: / Zip: / FEIN:
Contact Person: / Job Title of Contact Person:
Phone: / Email:
Name/Address of Parent Company:
Trainees Worksite Address:
Other/Previous DBAs (Doing Business As) and Location:
Type of Organization: (Check one)
□ Corporation □ Partnership □ Sole proprietary □ Public □ Other:______
Please answer the following information for the trainee(s) worksite location:
Date Established: / Chief Product or Service:
What is your NAICS Code? If not known, search for NAICS codes at the following website link:
Total # of employees: / # Full Time: # Part Time:
Will the OJT position(s) be covered under workers compensation? □ Yes □ No Carrier #:
Which benefits are provided to your employees for this position?: (Check all that apply)
□ Medical □ Dental □ Vision □ Other (describe) ______□ None
When will these benefits be made available to the OJT trainee(s)?
Do you have sufficient equipment, supervisory time and expertise to provide necessary training? □ Yes □ No
Are any employees currently on layoff? □ Yes □ No
If yes, what is the job classification(s) of employees currently on layoff?
Are there any outstanding wage and hour, health and safety, or discrimination complaints or adverse decisions?
□ Yes □ No Within how many years?
Is the business being sold, closed, relocated or merging with another company? □ Yes □ No
ATTESTATIONS:
This training provider has not relocated, leaving a loss of employment for any employee at the original location.
This organization is in good standing with federal and state organizations for this or any prior DBAs.
This training provider will provide performance information to OhioMeansJobs-Wayne County/ Wayne County Department of Job and Family Services when requested.*
It is understood that if approved to provide On-the-Job or Customized Training that this company/organization will be placed on a state-wide list** of eligible training providers. And further, that placement on the approved list does not guarantee training contracts will be written.
Are any of these positions covered by a collective bargaining agreement? □ Yes □ No
If so, obtain and attach a “concurrence letter” from the union(s).
I certify that the above information is, to the best of my knowledge, true and correct:
SIGNATURE: ______
Authorized Representative NamePosition Date
SIGNATURE: ______
OhioMeansJobs Caseworker SignatureDate
SIGNATURE: ______
OhioMeansJobs Program Supervisor SignatureDate
* Performance information includes end of contract retention rate, six month retention rate, increase in earnings, and skill achievements.
**Training providers would be removed from the list for failure to meet performance standards or failure to provide performance information.
Revised 8/24/17
Return completed form to Attention: OJT –OhioMeansJobs –Wayne County, PO Box 76, Wooster, OH 44691 or email to .
OhioMeansJobs-Wayne County(330) 264-5060