Workforce Development Denver Eligible Training Provider Application Part 1: PROVIDER INFORMATION 1. Provider/Organization Name:__________________________________________________________ 2. Mailing Address:____________________________________________________________________ 3. Physical Address/Location:____________________________________________________________ 4. Phone: ____________________________ Extension:_________________ Fax:_______________ 5. Website Address:____________________________________________________________________ 6. Contact Person:_____________________________________________________________________ 7. Title:___________________________________ 8. Phone:_________________ Ext.____________ 9. Email Address:_____________________________________________________________________ 10. Federal ID Number:_____________________ 11. Proprietary License #:_______________________ 12. Provider’s Facility is in compliance with the Americans with Disability Act (ADA): Yes 13. Provider is in compliance with the Equal Opportunity Act (EO): Yes No No 14. Provider has all applicable business licenses, (worker’s comp, etc.) on file with the State? Yes No 15. List any other names/entities the provider is doing business as or as a subsidiary of: 16. List all current/prior receipt of federal funds (WIA, TANF, Vocational Rehabilitation, etc.): Page 1 Part 2 – TRAINING PROGRAM/COURSE INFORMATION 1. Program Name:______________________________________________________________________ 2. CIP Code:________________________________ 3. ONET of Industry:_________________________ CIP Code - is the Classification of Instructional Programs code provided by the National Center for Education Statistics (NCES). ONET – is an 8 digit code describing the knowledge, skills, and abilities of a specific occupation. 4. Provider is listed on the State of Colorado Division of Private Occupational Schools (DPOS)? Yes No If No, is provider exempt based on Article 59 of the Colorado Revised Statutes Title 12 Professions and Occupations? List the type of Exemption below: DPOS is a state agency within the Colorado Department of Higher Education that is statutorily charged under the Private Occupational Education Act of 1981, et seq., of the Colorado Revised Statutes, with overseeing postsecondary private occupational schools and its delivery of occupational education. http://highered.colorado.gov/dpos 5. Provider is accredited by an accrediting agency recognized by the U.S. Secretary of Education? Yes No If Yes, list name of accreditations: _________________________________________________________________________________ 6. Length of training program, i.e. - Days, Weeks, Months, Years: _________________________________________________________________________________ 7. Indicate type of degree/certificate awarded upon completion of training: _________________________________________________________________________________ 8. Program Objective – Describe the objective of the program, what skills a student will acquire, what occupations a student will be qualified to apply for upon completion of the program, etc. 9. List all program pre-requisites: Page 2 9. List all program pre-requisites: __________________________ _________________________ 10. Financial Aid (select all that apply): Pell Grant Scholarships ________________________ Student Loans 11. Training Program Costs: Tuition:__________________________ Books:__________________________ Fees:____________________________ Total:___________________________ Part 3 – PERFORMANCE INFORMATION Performance Data for All Students: 1. # Of students enrolled in the program_______ 2. # Of students completing the program_______ 3. # Of students dropping the program_______ 4. # Of students obtaining credential/licensure_____ 5. # Of students obtaining unsubsidized employment______ 6. Wages at time of placement_______ Performance for Data WIA/WIOA Students: 7. # Of WIA/WIOA students enrolled_____ 8. # Of WIA/WIOA students completing the program_____ 9. # Of WIA/WIOA students obtaining unsubsidized employment____________ 10. Wages at time of placement________________ Certification: I certify that the information provided in this application is correct and true to the best of my knowledge. Willfully making false statements on this application or any attachments will deem this provider ineligible to provide services under the Workforce Investment/Workforce Investment Opportunity Act. Attestation: In accordance with the requirements of the Workforce Investment/Workforce Investment Opportunity Act, this facility will attest to the fact that the above performance data submitted is verifiable by program and can be made available for review upon request. Printed First & Last Name: _______________________________________________________________ Signature:____________________________________ Title:__________________________________ Date: _____________________________ Page 3