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Training Provider Acceptance
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Steps
1.
Step One
This section is complete
This section is incomplete
2.
Step Two
This section is complete
This section is incomplete
Step One
Participant Name
Social Security Number
Employ BR Center Locations
4523 Plank Road
Baton Rouge, LA 70805
Phone: 225-358-4579
Fax: 225-357-9675
1991 Wodddale Boulevard
Baton Rouge, LA 70806
Phone: 225-925-4312
Fax: 225-925-1845
Employ BR, in accordance with the Workforce Innovation Opportunity Act (WIOA), may offer financial assistance to WIOA eligible participants for skills training, which has been approved by the Workforce Investment Board (WIB). All training services provided must be in compliance with pertinent federal and state requirements and Employ BR policies, and will not exceed the allotted amount, inclusive of all costs. WIA is not an entitlement program. Any costs for training services expended through Employ BR are based on the availability of WIOA funds.
General Information
Training Provider Name
Training Program
Address
Training Hours
Start Date
Start Date
Projected Completion Date
Projected Completion Date
Participant Taking Online Course
Yes
No
Cost & Payment Information
Please list the training cost and indicate who receives payment.
Tuition Amount Cost
Including Registration Fee
Training Provider
Semester 1
Student Cost
Semester 1
Third Party
Semester 1
Training Provider
Semester 2
Student Cost
Semester 2
Third Party
Semester 2
Training Provider
Semester 3
Student Cost
Semester 3
Third Party
Semester 3
Training Provider
Semester 4
Student Cost
Semester 4
Third Party
Semester 4
Books
Training Provider
Student
Third Party
Supplies
Training Provider
Students
Third Party
Uniforms
Training Provider
Student
Third Party
Exam / Certificate
Training Provider Cost
Student Cost
Third Party Cost
Medical Cost - Training Provider
Medical Cost - Student
Medical Cost - Third Party
Federal Check Cost - Training Provider
Federal Check Cost - Student
Federal Check Cost - Third Party
State Board Fees - Training Provider
State Board Fees - Student
State Board Fees - Third Party
Other Fees
Please Specify
Training Provider
Student
Third Party
Total Training Provider Cost
All costs must be accurately reflected in Hire to covered by the WIOA Program.
Continue
Step Two
Training Referral
The above named Participant has begun the WIOA process for tuition assistance. When the Participant is approved for assistance the training provider will receive a Training Authorization form, based on availability of WIOA funds. This acceptance form does not constitute approval for WIOA funding.
The Student must return the original completed form with signature along with an itemized list of non-tuition cost to Employ BR no less than 10 business days prior to the first day of class for the designated training period.
The undersigned acknowledges that the above named Participant meets all requirements for and has been accepted into the above mentioned training program.
Training Provider Representative (Print Name)
Phone
Training Provider Representative Signature
Date
Financial Aid Information
Expected Family Contribution
Grant Period
Estimated Pell Grant (In Dollars)
Other Grants/Scholarships (In Dollars)
Subsidized Loan (In Dollars)
Unsubsidized Loans (In Dollars)
Total Assistance Available (In Dollars)
Participant Is Currently in Default
Yes
No
Financial Aid Representative (Print Name)
Phone
Financial Aid Representative Signature
Date
Supply List
If the student or third party receives payment, please provide an itemized list of books, supplies, and uniforms needed for this program.
If Applicable: Applicant successfully completed and passed all pre-requisites including required pre-requisite classes, drug screen, Motor Vehicle Report (MVR), etc.
Yes
No
EmployBR Use Only
Received By
Date
SVP Code
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