SCSEP HOST AGENCY Application
685800114300004244975118745DEPARTMENT OF EMPLOYMENT SERVICES00DEPARTMENT OF EMPLOYMENT SERVICESSCSEP HOST AGENCY Application Host Agency InformationHOST AGENCY NAME FORMTEXT ?????FEDERAL EMPLOYER IDENTIFICATION FORMTEXT ?????AGENCY STREET ADDRESS (No., Street, City, State, Zip) FORMTEXT ?????AGENCY MAILING ADDRESS (If different from above) FORMTEXT ?????AGENCY REPRESENTATIVE OR CONTACT NAME FORMTEXT ?????AGENCY REPRESENTATIVE TITLE FORMTEXT ?????PHONE NO.( FORMTEXT ?????) FORMTEXT ?????E-MAIL ADDRESS: FORMTEXT ?????FAX NO.( FORMTEXT ?????) FORMTEXT ?????Type of Agency FORMCHECKBOX Federal Government FORMCHECKBOX Non-Profit Organization (Tax exempt under 501 (c)(3) of the Internal Revenue Code of 1954)(Attach copy of IRS certification) FORMCHECKBOX State GovernmentPopulation Served by Agency FORMCHECKBOX General Population FORMCHECKBOX Over 55 PopulationAgency Description -Check the activity that best describes your agency’s focus: FORMCHECKBOX Conservation FORMCHECKBOX Community Betterment FORMCHECKBOX Health and Hospitals FORMCHECKBOX Social Services FORMCHECKBOX Counseling FORMCHECKBOX Employment Assistance FORMCHECKBOX Housing and Home Rehabilitation FORMCHECKBOX Other: FORMCHECKBOX Education FORMCHECKBOX Environmental Quality FORMCHECKBOX Public Works/Transportation FORMCHECKBOX Financial FORMCHECKBOX Legal FORMCHECKBOX Recreation, Parks, and ForestsDescribe other: FORMTEXT ?????Agency Purpose- FORMTEXT ?????Potential Assignments: Please list the positions you are interested in receiving assistance from SCSEP.Assignment Title FORMTEXT ?????Assignment Description FORMTEXT ?????Address FORMTEXT ?????Assignment Title FORMTEXT ?????Assignment Description FORMTEXT ?????Address: FORMTEXT ?????EmploymentEmployment- Will the agency be able to employ the participant upon successful completion of training? FORMCHECKBOX Yes, provided that funding is available. FORMCHECKBOX No, there is not a reasonable expectation that funding will be available.If no, what will the agency do to help the participant obtain employment? FORMTEXT ?????Please explain: FORMTEXT ?????Disclaimer and SignatureI verify that this training position constitutes a new expanded service and is not a violation of maintenance of effort regulations of the U. S. Department of Labor. (Positions of SCSEP participants shall be in addition to positions which otherwise would be funded by the local training site without the assistance from SCSEP. Positions funded under SCSEP shall result in an increase in employment opportunities over those which would otherwise be available may not result in the displacement of currently employed workers, including partial displacement such as reduction in hours, etc. may not employ or continue to employ a trainee to perform work the same or substantially the same as that performed by any other person who is on layoff.)AUTHORIZED AGENCY REPRESENTATIVES NAME AND TITLE (Print or Type): FORMTEXT ?????Signature: FORMTEXT ?????Date: FORMTEXT ????? ................
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