JS-52 (Rev
|JS-52 (Rev. 01/2015) Connecticut Dept. of Labor – Trade Adjustment Assistance (TAA) Training Application and Proposal |
|Name: |
|Last 4 of SSN: |
|Deadline Date |
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|Petition # |
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|Address: |
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|Phone # : |
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|Email Address: |
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|Trade Employer: |
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|Job Title: |
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|Training requested: Occupational skills Remedial Prerequisites for occupational skills On-the-Job (OJT) Customized |
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|I request approval to participate in the training described in this application. The information I provide is correct and complete to the best of my knowledge. I |
|understand that penalties are provided for willful misrepresentation made to obtain allowances to which I am not entitled. I understand that beginning TAA training will |
|void my ability to receive Alternative Trade Adjustment Assistance, if otherwise eligible. |
|* Has worker received Trade benefits under a prior certification in the past 10 years? Yes No |
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|Applicant signature |
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|Date |
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|TAA representative signature |
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|Date |
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|Email |
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|Phone |
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|Fax |
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|Job Center |
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|Employment goal with O*Net Code |
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|TO BE COMPLETED BY TRAINING FACILITY REPRESENTATIVE. Please provide the following information regarding the PROPOSED training program. The program length should be the |
|shortest period of time needed to achieve the desired results. |
|Name & address of training provider (employer if OJT) | |
| |Training program/course(s): |
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| |Will training lead to an AS degree Yes No If no, credential to be obtained: |
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|Training site if different |Start Date End Date Total calendar weeks of training |
|ESTIMATE OF TRAINING COSTS |No. of Hours Per Day OR |
|*If actual costs or dates are not known, estimate based on |MON |
|past practice. |TUE |
|Tuition |WED |
|$ |THUR |
| |FRI |
|Books |SAT |
|$ |Sun |
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|Fees | |
|$ | |
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|Uniforms | |
|$ | |
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|Health Insurance | |
|$ | |
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|General Supplies (Max $30 per semester, $15 summer) | |
|$ |No. of Credits Per Semester |
| |Fall |
|Other Materials (required by program) | |
|$ |Winter |
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|SUB TOTAL |Fall |
|$ | |
| |Winter |
|Less grants, non-loan financial aid, other $ | |
|$ |Fall |
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|TOTAL COST |Winter |
|$ | |
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| |Spring |
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| |Summer |
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| |Spring |
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| |Summer |
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| |Spring |
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| |Summer |
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| |Would the individual be participating on a full-time basis, in accordance with the training facility’s |
| |established hours and days of training? |
| |Yes No |
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| |Are any scheduled breaks in training greater than 30 days? If yes, attach facility’s published calendar or |
| |training schedule. |
| |Yes No |
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| |Will other vendors be involved in providing materials? If yes, identify vendor(s) and required supplies |
| |(attach list from school). |
| |Yes No |
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| |Does the training involve distance learning? If yes, attach a list of the specific program requirements or |
| |milestones. |
| |Yes No |
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| |CERTIFICATION: The undersigned certifies that estimates of training-related costs for training after the above|
| |start date have NOT been offset by any anticipated or received contributions from the training applicant or |
| |sources otherwise personal to the applicant, such as contributions from the applicant’s friends or relatives. |
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|Print Name and Title |
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|Signature of Authorized Representative |
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|Date |
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|Phone |
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|Fax |
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|Email |
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|TO BE COMPLETED BY LOCAL OFFICE TAA REPRESENTATIVE |
|Co-enrollment: Wagner-Peyser WIA VETS |
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|Number of miles from worker’s residence to training site: |
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|Method of transportation to training: |
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|Estimated cost of transportation and subsistence allowances, if any: |
|Total cost of proposed training including transportation and subsistence allowances: |
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|If contributions are expected from any other funding source(s), indicate amount below. |
|Subtract amount(s) at left, if any, for total cost to TAA |
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|WIA |
|Employer/Industry Council |
|Union/Labor Organization |
|Other (specify): |
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|A separate proposal must be submitted for each training provider. Attach address, phone and fax numbers for any vendor(s) involved other than the training provider. |
|Central Office Use Only: |
|Training is |
|approved denied |
|Signature and date |
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