Pinellas ITN

1. Respondent Information

Organization Name

Street/Mailing Address (Please click the address when the field populates)

Organization Contact Person

Title

Phone Number

Extension

Fax Number

Email Address

Website Address

Alternate Organization Contact Person

Alternate Title

Alternate Phone Number

Alternate Extension

Alternate Email

Date of Company Inception

Years in Business

Total number of Full-time Employees at this location

Legal Structure of Business

Employer’s Federal ID Number

Unemployment Comp ID Number

Dun and Bradstreet Number

Primary NAICS and or (SIC) Code

Is your company current on all State of Florida tax obligations?

The total amount your company will spend on training from July 1, 2018 - June 30, 2019

Is your company receiving/applying for other public training funds?

Description of your business, product(s) and/or service(s):

Amount of Grant Request from local CareerSource board

Number of Full-Time Employees to be Trained (must be Florida residents)

Training Start Date

Training End Date

Indicate industry sector that best fits your organization or type of training proposed

2. Proposed Training

Please provide the following information regarding the individuals and costs of the proposed training. Insert additional rows as needed.

Job Title of Individual(s) Receiving Training	Number Receiving Training	Avg. Rate of Pay Pre-Training - (Cannot exceed $26.00/hour before training)	Est. Rate of Pay Post-Training - (Cannot fall below $12.00/hour before training)	Training Provider	Type of Training – Course Name	Training Estimated Start Date	Training Estimated End Date	Certificate Issued/Recognized By:	Certification Name:	Classroom/ Training Hours	Actual Cost of Training/Tuition per Individual

3. Participating Parties

Based on your organization’s structure, please complete either the Employer Respondents OR Public Institutions of Higher Learning & Entities that carry out programs under the National Apprenticeship Act section below.

Employer Respondents: For each educational institution proposed to provide training, list the following information:

Training Provider Name	Contact Person	Address	Phone	Email Address	Institution Web Address	The training provider will be	Training will be delivered

Public Institutions of Higher Learning & Entities that carry out programs under the National Apprenticeship Act: List the following information for each employer you expect to participate:

Business Name	Contact Person	Address	Phone	Email Address	Number of Employees Anticipated to Participate

4. Budget

Employer Contribution

CareerSource Board Assistance Requested

Total

Direct Training Costs: Instructor Wages/Tuition inclusive of manuals/textbooks

Curriculum Development

Training Equipment Purchase (Must be employer contribution and cost prorated as a percentage for training time period.) Amount to be listed in dollars.

Facility Usage (If training takes place at company site)

Travel, Food, Lodging

Trainee Wages and Benefits

Subtotal

Indirect Costs

Total Employer Leveraged Resources

Total Direct Training and Leveraged Resources

6. Certification by Authorized Company/Institution Representative

The individual electronically signing the application below must have authority to enter into contracts on behalf of the applying organization/company.

As an authorized representative of the company/institution listed above, I hereby certify that the information listed above and attached to this application is true and accurate. I am aware that any false information or intended omissions may subject me to civil or criminal penalties for filing of false public records and/or forfeiture of any training award approved through this program.

Typing in your name serves as your electronic signature.

Name and Electronic Signature:

Title:

Email Address:

Today's Date:

7. File Uploads

Employers requesting reimbursement for in-house or internal training are required to clearly identify how the requested reimbursement amount of direct training costs is determined/calculated with their response. If applicable, please attach your supplemental documentation here:

(Previewing the document does NOT submit the application, rather allows you to review the application and print before submission.)

INVITATION TO NEGOTIATE #18-0462

Targeted Sector Initiatives (TSI): To Promote Career Ladder, Business Retention & Skills Upgrade Training For Employed Workers

2018-2019 QUESTIONNAIRE