San Bernardino County - Official Website
FORMCHECKBOX HIGH DESERT AJCC FORMCHECKBOX WEST VALLEY AJCC FORMCHECKBOX EAST VALLEY AJCC17310 Bear Valley Rd, Suite 109Victorville, CA 92395(760) 552-65509650 Ninth Street, Suite ARancho Cucamonga, CA 91730(909) 941-6500658 E. Brier Drive, Suite 100San Bernardino, CA 92415(909) 382-0440SECTION I : Customer Information (to be completed by WDS-Advisor)CUSTOMER’S FULL NAME (First Name, Middle Initial, Last Name):LAST FOUR DIGITS OF SSN: FORMTEXT ????? FORMTEXT ?????TELEPHONE NUMBER:EMPLOYMENT GOAL: FORMTEXT ????? FORMTEXT ?????REFERRAL DATE (mm/dd/yyyy):ASSESSMENT TEST RESULTS:FUNDING CATEGORY: FORMTEXT ?????Reading: FORMTEXT ?????Math: FORMTEXT ????? FORMCHECKBOX WIOA Adult FORMCHECKBOX WIOA DW FORMCHECKBOX Other (specify): FORMTEXT ?????SECTION II: WDD Contact Information (to be completed by WDS-Advisor)NAME & TITLE OF WDD STAFF REFERRING CUSTOMER FOR TRAINING: FORMTEXT ?????TELEPHONE NUMBER:FAX NUMBER:EMAIL ADDRESS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION III: ETPL Training Provider/Program Information (to be completed by WDS-Advisor)NAME OF TRAINING/SERVICE PROVIDER as listed on ETPL: FORMTEXT ?????COMPLETE ADDRESS (street, city, state, zip code) OF TRAINING/SERVICE PROVIDER as listed on ETPL: FORMTEXT ?????COURSE TITLE as listed on ETPL:COST OF COURSE/PROGRAM as listed on ETPL: FORMTEXT ?????$ FORMTEXT ?????SECTION IV: ETPL Training Provider Confirmation (to be completed by Training Provider)PROVIDER CONTACT PERSON (Name and Title): FORMTEXT ?????TELEPHONE NUMBER:FAX NUMBER:EMAIL ADDRESS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????IS CUSTOMER ACCEPTED FOR THIS COURSE?PROVIDE EXPLANATION ONLY IF CUSTOMER IS NOT ACCEPTED FOR COURSE LISTED IN SECTION III: FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????COMPLETE ADDRESS (street, city, state, zip code) OF THE SITE WHERE TRAINING SERVICES WILL BE PROVIDED: FORMTEXT ?????TRAINING ESTIMATED START DATE:TRAINING PROJECTED COMPLETION DATE:TOTAL NUMBER OF HOURS:TOTAL NUMBER OF WEEKS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TRAINING SCHEDULE; DAYS & TIMES (be specific: i.e., Monday, Wednesday, Friday = 8:00am-4:00pm; Tuesday, Thursday = 2:00pm-5:30pm; etc.): FORMTEXT ?????SECTION V: Training Cost / Financial Aid Information (to be completed by Training Provider)A.COURSE COST as listed on ETPL:$ FORMTEXT ?????B.MINUS Training Provider discount/scholarship: FORMCHECKBOX Federal FORMCHECKBOX Non-Federal $ FORMTEXT ?????C.MINUS Pell Grant: $ FORMTEXT ?????D.MINUS State CAL Grant (specify): FORMTEXT ????? $ FORMTEXT ?????E.MINUS Federal CAL Grant (specify): FORMTEXT ????? $ FORMTEXT ?????F.MINUS – Student Loan (specify organization): FORMTEXT ????? FORMCHECKBOX Federal FORMCHECKBOX Non-Federal $ FORMTEXT ?????G.MINUS – Student Loan (specify organization): FORMTEXT ????? FORMCHECKBOX Federal FORMCHECKBOX Non-Federal $ FORMTEXT ?????H.MINUS – Personal Loan (specify organization): FORMTEXT ????? FORMCHECKBOX Federal FORMCHECKBOX Non-Federal $ FORMTEXT ?????I.MINUS – Personal Loan (specify organization): FORMTEXT ????? FORMCHECKBOX Federal FORMCHECKBOX Non-Federal $ FORMTEXT ?????J.MINUS – Other (specify): FORMTEXT ????? FORMCHECKBOX Federal FORMCHECKBOX Non-Federal $ FORMTEXT ?????K.MINUS – Other (specify): FORMTEXT ????? FORMCHECKBOX Federal FORMCHECKBOX Non-Federal $ FORMTEXT ?????TOTAL WDD ITA CONTRACT AMOUNT (A minus B thru K):$ FORMTEXT ?????Customer’s Authorization and Release of Information: FORMCHECKBOX A financial needs analysis has been completed and financial aid is NOT available for this course. FORMCHECKBOX A financial needs analysis has been completed and financial aid IS available for this course. I have applied for financial aid and grant permission to the above service provider/contractor to release information regarding my financial aid package to authorized staff of the County of San Bernardino Workforce Development Department. My signature authorizes the above service provider/contractor to reduce the cost of training by the full amount of financial aid received on my behalf.Customer’s Signature: ________________________________________ Date: ____________________Customer’s Printed Name: _______________________________________________________________Training Provider Statement:The training provider understands and agrees that this referral shall not be construed as an obligation on the part of the County to purchase the specified training services unless the Director of WDD has authorized an Individual Training Account.Authorized Provider’s Signature: ______________________________________ Date: ________________Printed Name and Title: _____________________________________________SECTION VI: Authorization to Participate (for WDD Use Only)If “TOTAL WDD ITA Contract Amount” exceeds $3,000, obtain WD Manager signature. If cost exceeds $5,000, include Deputy Director signature. If cost exceeds $7,500, Director signature is required. WDS-ADVISOR PRINT NAME AND SIGN:DATE:DEPUTY DIRECTOR PRINT NAME AND SIGN:DATE:WD SUPERVISOR or MANAGER PRINT NAME AND SIGN:DATE:DIRECTOR PRINT NAME AND SIGN:DATE: ................
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