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PLEASE NOTE: Fillable forms are for print only. Forms containing original signatures must be submitted by mail, fax, or email.

Attach Employer Referral Agreement w/this page. Contact Training Vendor to confirm exact tuition amount(s).

SECTION I.

STATE WORKFORCE DEVELOPMENT DIVISION

Employment and Training Fund Program Course Registration/Agreement

(Please print or type)

Name of Participant:____________________________________________

Last, First, Middle Initial

Participant's E-mail : __________________________________________

Res Ph: (808) _________________________

Company Name: __________________________________________________________________________________

Contact Name: ______________________________________________

Bus Ph: (808) ________________________

Company Address: ____________________________________________

Fax Ph: (808) _________________________

Name of Training Vendor (School): ___________________________________ Location: ___________________________

ALL REQUESTS MUST BE SUBMITTED TO ETF BY THE EMPLOYER ON OFFICIAL STATE FORMS (LOCATED ON THE ETF WEBSITE AT )

ALL REQUESTS MUST BE SUBMITTED TO ETF BY THE EMPLOYER ON OFFICIAL STATE FORMS

IF SUBMITTING FORMS VIA FAX OR EMAIL, PLEASE CONTACT THE LOCAL OFFICE TO VERIFY RECEIPT OF YOUR REQUEST

(LOCATED ON THE ETF WEBSITE AT )

IF SUBMITTING FORMS VIA FAX OR EMAIL, PLEASE CONTACT THE LOCAL OFFICE TO VERIFY RECEIPT OF YOUR REQUEST

BREAKDOWN OF TUITION COST

Course

Course Title

Class Dates

ENTER

Total Tuition

No. &

DLIR/ETF

Employer's

Excess

Section

costs

balance

(See Section IV

(50% of ETF

exceeding

below)

assistance)

tuition cap

0.00

TOTAL

SECTION II. TO BE COMPLETED BY TRAINING VENDOR:

□

Enrollment confirmed by ________________________________________ ____________________________________

(Print/Sign Name of Authorized Representative)

AND

(Print Name of School)

SECTION III. (

To be completed by WDD/ETF only)

PO# _______________

Local Off. Control #________________

HONOLULU OFFICE

KONA OFFICE

HILO OFFICE

MAUI OFFICE

MOLOKAI OFFICE

KAUAI OFFICE

586-8703

327-4770

9 81-2860

984-2091

553-1755

274-3056

ENROLLMENT APPROVED BY: ____________

_________________________________ DATE ___/___/_____

WDD/ETF Representative, (print name here) :

SECTION IV. Employer/Training Vendor Agreement (This section must be completed by employer and training vendor)

EMPLOYER: The undersigned understands ETF assistance is defined as a tuition cap not to exceed $500 per course, including

tax, if applicable. Our company hereby agrees to pay fifty percent of the assistance, and any balance that exceeds the cap,

including tax if applicable, directly to the training vendor noted below prior to the start date of a class without liability to the State

DLIR. The Employer's total cost, including any excess balance, is $ ______________ (this amount does not include DLIR/ETF's

0% of the cost).

____________________________________

DATE (MM/DD/YY): ____________

Authorized Signature

________________________________

________________________

_____________________________________

Print Name

Title

Company Name

TRAINING VENDOR: The undersigned hereby agrees to be solely responsible for collecting directly from the employer noted

above $______________, which is the employer's total cost and does not include DLIR/ETF's 50% of the cost and hereby

agrees not to hold DLIR/ETF liable for any uncollected monies owed by the company named above. The undersigned agrees

that if the information provided herein is proven to be false, the DLIR may revoke any privilege to access ETF funds.

______________________ ________________________

__________________________________ DATE:_____________

Print Name

Authorized Signature

Print Name of Training Vendor (School)

Page 2 of 2

Revised February 2012

Employer Referral Agreement - Department Of Labor And Industrial Relations (Dlir), Workforce Development Division (Wdd) Page 2

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