WORKFORCE DEVELOPMENT DIVISION INDIVIDUAL TRAINING ACCOUNT/INDIVIDUAL REFERRAL PART I WIA Enrollment Approval - completed by Alabama Career Center 3. ITA/IR 1. Student Name 2. Social Security Number Number Dis. Gov. Set. Adult Youth Wkr. 5. Location/Campus 6. Curriculum 4. Education Training Provider Up to: A. Beginning 7. Training 8. #of weeks (max Cost 9. Date 104) Allocation A. Original Schedule B. Ending 10. #of semesters Category of B. 11. Date Form Reenrollment 12. Last Employer: 13. Rapid Response: YES NO 14. Case #: 15. Reason for Leaving: Plant Closure Lay-Off Other (Explain): Lay-off 16. Concurrent Enrollment in TAA: Yes No If Yes, Enrollment Case #: (Explain) Yes 17. Pell Grant: YES NO No 18. Comments: If Yes, Enrollment Case# Signature of Enrolling Agency Representative Enrolling Agency Date Phone Number Enrolling Approval: Signature of Authorized Representative: Instructions: Alabama Career Center completes all blocks required. Mail original to WDD, P.O. Box 5690, Montgomery, AL 36103-5690, for approval and WDD distributes to ITA Payment Office. ITA Payment Office will distribute to Alabama Career Center (Alabama Career Center will distribute to Training Provider). Amendments to Part 1 - Alabama Career Center must complete amendment form. Part CONTRACT- completed by Training Provider budget items represent the training provider's official WIA budget for the student named above and is completed and submitted once the student begins training. $ - 1. Per Semester Tuition Other@ Per $ - 2. Fees, insurance, etc. (list items and cost) 3. Tools (list items and cost) 4. Other (list items and cost) 5. Total If this is an amendment - Comments Workforce Development Division Date Training Provider’s Authorized Date Representative Representative Instructions: Training Provider completes Part II and submits 4 copies with an original signature to ITA Payment Office ITA Payment Office will distribute to WDD, Alabama Career Center, and Training Provider Amendments to Part II Training Provider must complete amendment form. –
WORKFORCE DEVELOPMENT DIVISION INDIVIDUAL TRAINING ACCOUNT/INDIVIDUAL REFERRAL PART I WIA Enrollment Approval - completed by Alabama Career Center 1. Student Name 2. Social Security Number 3. ITA/IR Number Adult Youth Dis. Wkr. Gov. Set. 4. Education Training Provider 5. Location/Campus 6. Curriculum 7. Training Schedule A. Beginning Date 8. #of weeks (max 104) 9. Cost Allocation Up to: B. Ending Date 10. #of semesters 11. Category of Form A. Original B. Reenrollment 12. Last Employer: 13. Rapid Response: YES NO 14. Case #: 15. Reason for Leaving: Plant Closure Lay-Off Other (Explain): Lay-off (Explain) 16. Concurrent Enrollment in TAA: Yes No If Yes, Enrollment Case #: Yes No If Yes, Enrollment Case# 17. Pell Grant: YES NO 18. Comments: Signature of Enrolling Agency Representative Enrolling Agency Date Phone Number Enrolling Approval: Signature of Authorized Representative: Instructions: Alabama Career Center completes all blocks required. Mail original to WDD, P.O. Box 5690, Montgomery, AL 36103-5690, for approval and WDD distributes to ITA Payment Office. ITA Payment Office will distribute to Alabama Career Center (Alabama Career Center will distribute to Training Provider). Amendments to Part 1 - Alabama Career Center must complete amendment form. Part CONTRACT- completed by Training Provider budget items represent the training provider's official WIA budget for the student named above and is completed and submitted once the student begins training. 1. Tuition Per Semester $ - Other@ Per $ - 2. Fees, insurance, etc. (list items and cost) 3. Tools (list items and cost) 4. Other (list items and cost) 5. Total If this is an amendment - Comments Workforce Development Division Representative Date Training Provider’s Authorized Representative Date Instructions: Training Provider completes Part II and submits 4 copies with an original signature to ITA Payment Office ITA Payment Office will distribute to WDD, Alabama Career Center, and Training Provider Amendments to Part II – Training Provider must complete amendment form.
AWIAITAGuidelines.docx