Free 52729.xls - Indiana

PRE-APPLICATION FOR TRAINING ACCELERATION GRANT COMPANY INFORMATION
State Form 52729 (7-06) INDIANA WORKFORCE DEVELOPMENT

Company Name: Street Address: City: Fein: State: Zip Code: NAICS: County:

Consortium Agreement
Is your organization applying on behalf of a consortium of three (3) or more companies?
YES NO

If applicable, please list the names of the participating companies using List of Consortium Participants.

Project Information
Briefly describe the proposed training plans and credentials:

Employment Information
Current Employment Level Has your company experienced any non-seasonal layoffs in the past 12 months?
YES

Employment Level 12 Months Ago
NO

Briefly explain layoffs.

Contact Information Primary Contact
Primary Contact Name: Primary Contact Title: Phone Number: Fax Number: e-mail address:

Secondary Contact
Secondary Contact Name: Secondary Contact Title: Phone Number: Fax Number: e-mail address:

State Funds Received Annually
List amounts for all state funds being received annually: Training Acceleration Grant (TAG) TECH Fund Skills Enhancement Fund (SEF) Other:

I agree to accept email attachments from Indiana Workforce Development with regard to the required submission of the material applicable to the Training Acceleration Grant Program.

Signature

Date

For Internal Use Only
Clear Not Clear

Printed Name and Title Clearance check date: Clearance check by: