Form Eo-364 - Penndot Ojt Program Enrollment Form
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3EO-364 (1-11)
PennDOT OJT PROGRAM ENROLLMENT FORM
Project Information
ECMS Number
Federal Project Number
100% State Funded:
S.R. Number
Sec. Number
PA Engineering District
o Yes o No
Telephone/Cell Phone Number
Email Address
PROJECT
PennDOT ______________________________________
o
MANAGED
Telephone/Cell Phone Number
Email Address
BY:
Consultant ______________________________________
o
Contractor Information
Training Provider's Name
Telephone Number
Email Address
Prime Contractor's Name
Is Training Provider Union Contractor?
o Yes o No
Project Office Address
City
State
Zip Code
Project Office Contact:
Telephone Number
Email Address
Training Providers EEO Officer's Name
Telephone Number
Email Address
Trainee Candidate Information
First Name
M.I.
Last Name
Social Security Number
Gender
o Male o Female
Street Address
Apt./Unit Number
City
State
Zip Code
Telephone/Cell Phone Number
Do you have any experience in the proposed training classification?
If YES, please explain:
o Yes o No
Race/Ethnicity
If you selected Other, please specify:
Select One
Training Information
PennDOT-Approved Training Classification Title (Program Number)
Program Hours
Anticipated Start Date
This Training Position is being Filled by an:
If "Other" or "New Union Member" Identify Candidate's Current Status:
o OJT o Apprentice o New Union Member o Other
Upgrade Current Employee?
Current Employee's Work Classification
o Yes o No
Apprenticeship Construction Craft Classification
Apprentice Hours
Already Completed
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Parent category: Legal