Company/Open Enrollment:

Authorized Company Representative Name:

Company Representative Phone Number:

Company Representative Email Address:

Company Address:

City:

State: AL AK AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Not Listed

Zip Code:

Target Business/Industry:

Job Preparation:

Placement Opportunity:

Employee Upgrade:

Average Wage:

Wage Increase:

Proposed Project/Program

Program Title:

Training Proposed: (description)

Training Proposed Start Date:

Training proposed End Date:

Unduplicated Headcount:

Contract Hours Proposed:

Number of Sessions:

Instructor/Vendor Name:

Instructor/Vendor Phone Number:

Instructor/Vendor Email Address:

Location of Training:

Budget

Tuition:

Employer Contribution:

Administration Fees:

Instructional Supplies:

Instructor Fees:

Other Identified Fees:

Acceptance of the Terms and Conditions of a CTE Grant

As recipient of a CTE STIT funds, I attest that I have read and agree to comply with the STIT Guidelines and Procedures, which include the terms and conditions of the award. I further acknowledge that failure to comply with these terms and conditions may result in consequences and/or penalties, including withdrawal of the funds.