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Name of Business Street Address / PO Box City State ZIP Code Mailing Address (if different than above) City State ZIP Code Training Program Position Title E-mail Address Cell Phone Number Telephone Number Federal Tax Identification Number Number of Full-Time Employees Please check the box(es) that apply to your agency or business: Corporation Partnership Nonprofit Organization Individual Ownership Public Agency Other How many hours per week will the trainee work What is the business product or service Number of Positions Requested Proposed Starting Wage per Hour Proposed Starting Date Proposed Wage at End of Training List major job duties and / or areas in which the employee will receive training..
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