Vermont Official State Website

Online WIOA Training Provider Application

Please complete and submit this application to be considered for eligibility as a Training Provider Under the Workforce Innovation and Opportunity Act (WIOA)

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This Application is a: *

Initial Application

Renewal Application

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PROVIDER INFORMATION

Name of Training Provider *

Federal EIN *

Address *

Address line 2

Training Facility Address (If Different)

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Website Address *

Provider Contact Person *

Provider Telephone Number *

Provider Email Address *

Applicant Title *

Owner, CEO, program director, ect.

The training facility meets the requirements of the Americans with Disabilities Act (ADA)? *

Yes

Please email the following items to Sarah.Buxton@vermont.gov

Program catalog/brochure

Current class schedule

Policies [specifically, tuition refund, EEO and Accessibility policies]

Type of Training: (check all that apply) *

Occupational Skills Training

College Credit Program

Number of College Credits (if applicable)

Describe how the programs leads to any recognized post-secondary credentials (See Footnote 1) *

Footnote 1. 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). - -

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

Type of License or Certification *

License or Certification Entity *

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TOTAL HOURS OF INSTRUCTION

Contact Hours *

Credit Hours *

Number of Semesters or Hours Required *

Delivery Method: (check all that apply) *

Online

Classroom

On-the-Job site

Other

If "Other" Please Describe

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CLASS SIZE AND LOCATION

Course Location *

Minimum Class Size (If applicable)

Maximum Class Size (If applicable)

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PROGRAM APPROVALS

Are students in the program eligible for Pell Grants under Title IV of the Higher Education Act of 1965? *

Yes

If yes, date of certification granted by U.S. Department of Education

Is this program approved by the Vermont State Board of Education? *

Yes

Is the program approved by the U.S. Department of Education or other State Board of Education? *

Yes

Which State? *

Which Agency? *

Name of Professional Association: *

If provider or program is a certified training provider in other state(s); please enter state(s):

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PROGRAM DESCRIPTION

Brief Description of Training Program *

Describe the minimum program entry requirements: *

e.g. reading or math level, high school diploma or GED, other education or experience requirements

List the businesses (employers) that you have worked with to develop this training curriculum *

Including Business Name, Address, Key Contact, and Phone number

Describe how the program aligns with with the in-demand industry sectors and occupations in Vermont *

List the businesses (employers) that have expressed an interest in, or commitment to, hiring individuals who complete this training *

including business name, address, key contact, phone number

Describe the support services available to students *

Describe the financial assistance available for students *

Describe any discounts or other allowances that will be given to WIOA participants *

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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) * $

Total Cost (per student out‐of‐state) * $

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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).

From (Date): *

Day

Month

Year

To (Date): *

Day

Month

Year

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NUMBER OF PROGRAM PARTICIPANTS

- -

Training Program Title *

# Enrolled *

# Completed *

# Of WIOA Participants *

# of WIOA Completed *

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The percentage of program participants who are in unsubsidized employment during the second quarter after exit from the program

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% of All Students * %

% of WIOA Students * %

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The percentage of program participants who are in unsubsidized employment during the fourth quarter after exit from the program

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% of all participating students * %

% of all participating WIOA students * %

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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 * %

Percentage of all WIOA Participants * %

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Where appropriate, rate of successful completion by all participants of:

Licensure # *

Licensure Percent * %

Professional Certificate # *

Professional Certificates % * %

Attainment of Degrees # *

Attainment of Degree % * %

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Note: The Eligible Training Provider will likely need to work with the VDOL in order to complete #3-5, above.

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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.

Certified by: *

This constitutes my electronic signature

If this box is checked, this submission shall be considered as an authorized written signature.*

Name of Authorized Official *

Signatory's Official Title *

Name of Organization *

Date of Submission *

Day

Month

Year

If the Vermont Department of Labor, after consultation with the State Workforce Development Board, determines that a training provider intentionally provided inaccurate information, or determines the provider has substantially violated any requirements of the Workforce Innovation and Opportunity Act, eligibility shall be terminated and all funds received for the program during the period of non-compliance shall be repaid.

Contact Information

Vermont Department of Labor
5 Green Mountain Drive
P.O. Box 488
Montpelier, 05601-0488
(802) 828-4000

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