OJT Grant Application Data Sheet

Notify

Select one

New Contract

Existing Agreement

OJT Agreement Execution Date:

EMPLOYER INFORMATION

Legal/Official Name of Organization:

Type of Organization:

Corporation

Professional Association

Professional Corporation

Occupational Lic. #:

FEIN

Workers Comp. #:

NAICS Code:

Brief Organization Description:

Number of employees

Hourly Wage:

Reimbursement Rate: (%)

Is this for seasonal employment?

Yes

No

Working Conditions Observed:

Safety Procedures:

Enterprise Zone:

Apprenticeship Programs:

Meeting Retention Requirements:

Yes

No

Do collective bargaining agreements cover the occupations in which training is proposed?

Yes

No

List bargaining agents & occupations:

List Holiday Office Closure Dates:

ADDITIONAL INFORMATION

Job Title for Proposed OJT Training:

Is this OJT for an occupation on the Palm Beach County Targeted Occupations List?

Yes

No

List SOC Code:

Has anyone performing the job listed for the proposed OJT been laid off by the employer in the last two months?

Yes

No

Does employer have the necessary equipment, resources and supervision to perform the training?

Yes

No

Has employer contracted with CSPBC in the past?

Yes

No

What programs (include dates)?

Will the proposed OJT position(s) be contracted through a staffing agency?

Yes

No

Who is the employer of record (who issues the payroll check)?

Will the proposed OJT position require additional training or certifications after the completion of the OJT in order to retain this job?

Yes

No

This proposed OJT is for the salaried job listed above. Will this job remain in salary status after the completion of the OJT?

Yes

No

Does this Employer have representation on the Palm Beach County Workforce Development Board?

Yes

No

TRAINING LOCATION

Street Address

City

State

Zip Code

Is the worksite the same as the training location stated above?

Yes

No

WORKSITE LOCATION

Street Address

City

State

Zip Code

PERSON AUTHORIZED TO SIGN OJT CONTRACTS OR DESIGNEE

Is the individual signing as an owner or officer?

Owner

Officer

Full Name

Title

Street Address

City

State

Zip Code

Office Phone

Mobile Phone

Fax

Email Address

Do you recommend proceeding with the Contract?

Yes

No

Why?

OJT Candidate Name

State ID

Under penalties of Perjury, I declare that I have examined this request and to the best of my knowledge and belief, it is true, correct and complete.

Business Services Staff Name

Signature

Sign Here

Date

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