Employer Referral Agreement - Department Of Labor And Industrial Relations (Dlir), Workforce Development Division (Wdd)

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PLEASE NOTE: Fillable forms are for print only. Forms containing original signatures must be submitted by mail, fax, or email
EMPLOYMENT & TRAINING FUND (ETF)--EMPLOYER REFERRAL AGREEMENT
Department of Labor and Industrial Relations (DLIR), Workforce Development Division (WDD)
Employer or Authorized Representative: ______________________________________ Title________________________
Address ____________________________________________________________ City_______________ Zip__________
Federal ID#___________________ Phone:__________ Fax:___________ E-Mail:______________________________
Company (dba) ______________________________________ Parent Company__________________________________
Type of Business ________________________________ # Employees_____________
For Profit
Non-Profit
Employer or Payroll Service Provider's DOL # ________________ Name of Payroll Service (if applicable): _______________________
EMPLOYER: I certify that 1) the requested training is necessary to improve or upgrade the workforce skills of the employee listed
below; 2) our company does not already provide for the requested training; 3) the employee listed below is not a government
subsidized employee of this company; and 4) the information provided herein is true and if proven to be false, may result in the DLIR
revoking our company's privileges to access ETF funds.
Our company understands ETF's assistance is defined as a tuition cap not to exceed $500 per course and we hereby agree to:
1) pay fifty percent (including tax, if applicable) of the ETF assistance and any excess balance thereof that exceeds the assistance directly
to the training vendor prior to the start date of a class without liability to the State; 2) notify the training vendor and ETF of any enrollment
cancellations or substitutions at least 5 days prior to the start date of the class; and 3) participate in any relevant training evaluations or
follow-up surveys the DLIR may request. (Note: For substitutions, a separate Employer Referral Agreement form must be completed and
mailed to ETF for approval). It is understood that our company will be responsible for any costs incurred for not complying with the above
terms and failure to do so would result in the employer or employee being suspended from accessing ETF funds for a period of one year or
more and the DLIR-WDD may disapprove or terminate this Agreement at any time without liability to the State.
Authorized Employer Signature______________________________________________________ Date ____/____/___
Print Name__________________________________ Title_______________________________ Phone_______________
EMPLOYEE INFORMATION will be used by DLIR to track training data. The training vendor listed below will receive
name and work/alternate phone number(s) for registration, cancellation, and/or reminder purposes.
Last name _______________________________ First name ___________________________ Initial ______ Sex: Male
Female
Job Title_____________________________
Owner
Supervisor/Manager
Employee Highest Grade Completed_____
Work Phone_______________Alt. Phone_______________ E-mail _____________________________________________
U.S. Citizen:
Yes
No If no, attach copy of official documents showing legal right to work in the United States.
ALL REQUESTS MUST BE SUBMITTED TO ETF BY THE EMPLOYER ON OFFICIAL STATE FORMS
(LOCATED ON THE ETF WEBSITE AT )
IF SUBMITTING FORMS VIA FAX OR EMAIL, PLEASE CONTACT THE LOCAL OFFICE TO VERIFY RECEIPT OF YOUR REQUEST
THIS REQUEST MUST BE RECEIVED BY ETF AT LEAST 2 WEEKS PRIOR TO THE START DATE OF A CLASS
ATTACH ETF COURSE REGISTRATION FORM AND SUBMIT WITH THIS FORM TO ETF WHEN REQUESTING TRAINING*
Request for Training Vendor: ____________________________________________________________________
I hereby authorize the training vendor noted above to release any of the above information to the State Department of Labor and Industrial Relations to
track employee services and training data. I agree to complete all classes & activities as scheduled and participate in DLIR evaluations of any training
received through ETF. I understand and have discussed with my employer the above terms. I am currently not qualified for any other federal, state or
county training programs. I understand if I fail to attend a class without properly notifying ETF, the DLIR shall impose upon me a one-year
suspension from the ETF Employer Referral Program for the first occurrence and a lifetime suspension for any additional no-shows. I agree that
if the information provided herein is proven to be false, the DLIR may revoke my privilege to access ETF funds.
Employee Signature: ______________________________________________________________ Date____/____/____
Print Name:__________________________________________
Auxiliary aids and services are available upon request. Call ETF at 808/586-8847 (TTY), or 1/888/569-6859 (TTY Neighbor Islands). It is the policy of DLIR that no person
shall, on the basis of race, sex including gender identity or expression, sexual orientation, age, religion, color, ancestry/national origin, disability, marital status, civil union
status, arrest and court record (except in limited circumstances), or domestic or sexual violence victim status., and National Guard participation, be subjected to discrimination,
excluded from participation in, or denied the benefits of DLIR’s services, programs, activities, or employment.
* BEFORE ATTENDING CLASS , DLIR MUST GIVE PRIOR WRITTEN APPROVAL . CHECK WITH YOUR EMPLOYER TO CONFIRM ENROLLMENT
ETF ONLY: Approved by WDD Branch: _________________
BY ______________________________________________Date:_____/_____/_____
Local Office Control # ________________ ETF (50%) Cost $_____________Employer's (50%) Cost $_____________ Employer's excess balance $_____________
PAGE 1 of 2
Revised February 2012

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