Incumbent Worker Training Program (IWTP)

Customized Training Web-Based Application Signature Page

 

Certification of Employer, Training Provider and LWC IWTP Representative:

 
 
 
   Application Date:  10/26/2014 4:29:02 AM
 
 
 
   Application Number: Sample  
 


PRIMARY EMPLOYER (or Consortium Coordinator) INFORMATION

Employer (or Consortium) Name: Sample C.E. Test Co.
Contact Name: Sample E.M. Ployer
Street Address:  
1234 Sample Ave.
City, State, Zip: Baton Rouge, LA, 70804
Mailing address: P.O. Box 1234 
City, State, Zip: Baton Rouge, LA, 70801
Telephone Number: (225) 123-4567 
Fax Number: (225) 765-4321 
Email Address: Sample_Employer@lwc.la.gov

PRIMARY TRAINING PROVIDER INFORMATION

Training Provider Name: LWC Sample Training Co.
Authorized Application Signee & Title: Sample TPA. Signee, Owner
Street Address: 123 Sample TP Dr.
City, State, Zip: Baton Rouge,LA,70804
Contact Person's Name: Sample Trainer
Telephone Number: (225) 123-4567 
Fax Number:  
Email Address: SampleTrainer@lwc.la.gov
I hereby certify that all information provided in this application is true and correct and I am aware that false information or lack of information knowingly made or omitted may subject me to civil or criminal penalties for filing of false public records, and/or forfeiture of any training award approved under this program.
I understand that employers seeking a training award  may not select as a training provider:
a. any entity who principal owner is an immediate family member, as defined in the Code of Governmental Ethics, of an individual in a management position with the employer who has the authority to make decisions regarding the training program; or
b. any related business such as a parent, subsidiary or partner of the employer.

In addition, if the training project outlined in this application is recommended for approval, I understand that one or more of the following items is required of employers and private training providers before the contract can be executed:
(__)    Copy of the W-9 form - Request for Taxpayers Identification Number and Certification.
(__)    Stamped copy of Disclosure of Ownership that has been properly filed with the Secretary of State's Office if the employer or training provider is a for-profit corporation whose stock is not publicly traded.  Note:  Employers or private training providers are exempt from submitting this if they are any of the following:  non-profit, publicly traded, sole proprietorship, Louisiana medical corporation, Limited Liability Company, electric or gas service corporation, state chartered bank, or partnership.
(__)    A Board Resolution authorizing signature for the corporation for contract purposes, if the employer or private training provider is a corporation, profit or non-profit. Note:  Employers or private training providers are exempt from submitting this if they are a partnership or an individual.
(__)    Consortium Members may each need to provide a Company Overview Form.
   
Industry, Training Provider, and LWC Collaboration
I hereby certify that this application is the result of a collaborative effort of all parties listed below. All parties have met to discuss training needs, costs, available resources including location of training, curriculum, equipment, materials and supplies, etc.


 
Authorized Consortium Signature


 
Date Signed


 
Typed/Printed Name of Authorized Consortium Signature


 
Training Provider's Authorized Application Signature


 
Date Signed


 
Typed/Printed Name of Training Provider's Authorized Application Signature


 
Authorized LWC Regional IWTP Specialist Signature


 
Date Signed


 2
Region


 
Typed/Printed Name of Authorized LWC Regional IWTP Specialist Signature

Note: Written contract approval from LWC will be required prior to the start of any training.