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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.):
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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:
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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: _____________________________
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