PROVIDER INFORMATION
Name of Training Provider *
Federal EIN *
Address *
Address line 2
Website Address *
Provider Contact Person *
Provider Telephone Number *
Provider Email Address *
Please email the following items to Sarah.Buxton@vermont.gov
Program catalog/brochure
Current class schedule
Policies [specifically, tuition refund, EEO and Accessibility policies]
Number of College Credits (if applicable)
If the program is intended to prepare the student for licensure or certification, list the type of license and the name of the licensing or certifying entity
TOTAL HOURS OF INSTRUCTION
Contact Hours *
Credit Hours *
Number of Semesters or Hours Required *
CLASS SIZE AND LOCATION
Course Location *
Minimum Class Size (If applicable)
PROGRAM APPROVALS
If yes, date of certification granted by U.S. Department of Education
Which State? *
Which Agency? *
Name of Professional Association: *
PROGRAM DESCRIPTION
Describe the minimum program entry requirements: *
e.g. reading or math level, high school diploma or GED, other education or experience requirements
COST INFORMATION (per semester, per student)
Semester Tuition (in‐state Vermont) *
Semester Tuition (out‐of‐state) *
Fees *
Books (Estimate) *
Uniforms (Estimate) *
Room and Board (estimate) *
Tools (Estimate) *
Other
Total Cost (per student in‐state) *
$
Eligible Training Provider Performance Information
(Complete One Performance Information Sheet for Each Program)
Twelve‐month period of performance for training program being reported: For an initial eligibility determination, the Training Provider should provide any accurate information related to the requested performance measures and certify to the VDOL the ability to meet minimum performance levels and accurately submit the required information at the end of the performance period. Contact the VDOL, Workforce Development Division for further information (802-828-4151).
NUMBER OF PROGRAM PARTICIPANTS
Training Program Title *
# Enrolled *
# Completed *
# Of WIOA Participants *
The percentage of program participants who are in unsubsidized employment during the second quarter after exit from the program
% of All Students *
%
The percentage of program participants who are in unsubsidized employment during the fourth quarter after exit from the program
% of all participating students *
%
The percentage of participants who obtain: a recognized post-secondary credential, secondary school diploma or its recognized equivalent participation in or within one (1) year after exit from the program. Participants who obtain a secondary school diploma or its recognized equivalent shall be included only if such participants, in addition to obtaining such diploma, have obtained or retained employment or are in an education or training program leading to a recognized post-secondary credential within one (1) year after exit from the program.
Recognized post-secondary credential-The term "recognized post-secondary credential" means a credential consisting of an industry-recognized certificate or certification, a certificate of completion of an apprenticeship, a license recognized by the by the State involved or Federal Government, or an associate or baccalaureate degree.
Percentage of all Students *
%
Where appropriate, rate of successful completion by all participants of:
Licensure # *
Licensure Percent *
%
Professional Certificate # *
Professional Certificates % *
%
Attainment of Degrees # *
Note: The Eligible Training Provider will likely need to work with the VDOL in order to complete #3-5, above. AUTHORIZED SIGNATURE: -
By signing, I hereby certify that all information provided in this application package (including attachments) is accurate as of the date of submission. I further certify my understanding that any or all of the items included in the application may be displayed as part of the Vermont list of WIOA-approved training providers. As a potential recipient of funds from WIOA this organization agrees to comply with non-dis-crimination provisions of the WIOA located in Section 188 and 29 CFR 37. By signing this document the Training Provider agrees to comply with the WIOA reporting requirements.
Name of Authorized Official *
Signatory's Official Title *
Name of Organization *
