RI GWB NonTrad Apprentice

EMPLOYER INFORMATION

The Non-Traditional Apprenticeship Incentive Program will provide an incentive of $1,000 per non-trade apprentice registered subsequent to January 1, 2016 and after the completion of the required probationary period. Employers shall be eligible for up to $5,000 in monetary incentive within any 12 month period.

NOTE: Non-trade apprenticeships are apprenticeships that are registered with the Department of Labor and Training that are outside of the construction trades. The required probationary period is a standard that established as part of the apprenticeship approval process and will vary based on the apprenticeship model.

The employer must submit a completed approval form and signed federal W-9 form (for the employer). Funds will not be awarded for any non-trade apprentice that has not completed the required probationary period.

Employer Name: *

Employer NAICS Code: *

If not sure, visit: www.naics.com/search/

Employer Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Contact Person *

First Name Last Name

Contact Person Job Title *

Phone Number *

Area Code Phone Number

Contact Person Email *

NAME of Apprenticeship Program *

APPRENTICE INFORMATION

Apprentice Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

E-mail *

Date of Birth

Month Day Year

Apprentice Gender (Optional)

Male Female

Apprentice Age (Optional)

18-24 Years old 25-54 Years old 55+ Years old

Apprentice Race/Ethnicity

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Hispanic/Latino Other/Multiracial

Upload a Signed Copy of W9 Tax Form *

https://www.irs.gov/pub/irs-pdf/fw9.pdf

I certify that all information contained in this application and proposal is true and accurate and I understand that falsification of information may be cause for non-review or award revocation. I certify that the applicant organization is current on all Rhode Island tax obligations, must be in good standing with all divisions and programs administered by the Department of Labor and Training and must not have been debarred (prohibited) from contracting with an agency that administers federal funds. I understand that I have acquired no property or other right by virture of submitting this application. If awarded, I agree to comply with the terms and provisions of this proposal.

(The name below must be of an individual with authority to enter into legally binding agreements on behalf of the applicant).

Name of Person Completing Application *

First Name Last Name

Job Title *