ETA Form 671, Part Group Program Participating Employer Tear-Off

ETA Form 671, Part IA - Group Program Participating Employer Tear-Off OMB Control No. 1205-0NEW

Expiration Date: xx/xx/xxxx

ETA Form 671, Part IA - Group Program Participating Employer Tear-Off

Section A. PROGRAM INFORMATION
1. Sponsor Name	2. Program Number								3. RAPIDS Code
4. Name of Occupation Determined Suitable for Registered Apprenticeship Training
Section B. PARTICIPATING EMPLOYER INFORMATION
1. Name of Participating Employer
2. Participating Employer’s Primary Point of Contact (Last, First, Middle Initial)						3. Title of Primary Point of Contact
4. Address
5. City				6. State					7. Zip Code
8. Telephone Number		9. E-mail Address					10. Cell Phone Number (Optional)
11. Employer Identification Number (EIN) of Participating Employer				12. NAICS Code of the Participating Employer					13. Size of the Participating Employer’s Workforce
Section C. WAGE INFORMATION
1. Journeyworker Entry Wage			2. Apprentice Entry Wage					3. Apprentice Final Wage
4. Are Wages Paid During Related Instruction? (Select One) Yes No If yes, Enter Wage Amount:			5. Hours When Related Instruction is Provided (Select One) During Work Hours Not During Work Hours Both During and Not During Work Hours
6. Wage Rate (Select One) % of Journeyworker Entry Wage $ amount of wage Both % and $ amount of wage
7. Wage Progression Schedule
a. Wage Progression Step			b. Hourly Wage/ % of Journeyworker Entry Wage (If Applicable)					c. Duration (If Applicable)		d. Number of Competencies (If Applicable)
1.)
2.)
3.)
4.)
5.)
6.)
7.)
8.)
9.)
10.)
7. Fringe Benefits [if applicable] a. Does the sponsor or any participating employer provide fringe benefits to apprentices? (Select One) Yes No b. If yes, please select any fringe benefits that apply: Health Insurance Contribution Life Insurance Pension/Retirement Contribution Vacation Sick Leave Paid Holidays Other “bona fide” fringe benefits Please list: ______________ c. If yes to item 7a above, please provide an approximate hourly value of the total fringe benefits provided.      
Section D. SIGNATURES
1. Name of Individual Signing on Behalf of the Participating Employer					2. Title of Individual Signing on Behalf of the Participating Employer
3. Signature					4. Date
5. Name of Individual Signing on Behalf of the Program Sponsor					6. Title of Individual Signing on Behalf of the Program Sponsor
7. Signature					8. Date
9. Registration Agency					10. Name of Registration Agency Representative
11. Signature					12. Date

PLEASE NOTE: Once this form has been completed, return to ETA Form 671, Part I to complete Section J (Academic Credit and Interim Credentials) and proceed to complete the remainder of the form. After the sponsor has completed the wage information for each participating employer in ETA Form 671, Part 1A, please attach each completed ETA Form 671, Part 1A to the program sponsor’s ETA Form 671, Part I - Program Registration.

Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average ten minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond is required to obtain or retain benefits under 29 U.S.C. 50. Send comments regarding this burden or any other aspect of this collection of information including suggestions for reducing this burden to the U.S. Department of Labor, Employment and Training Administration, Office of Apprenticeship, 200 Constitution Avenue, N.W., Room C-5321, Washington, D.C. 20210 or email OA-ICRs@dol.gov and reference OMB Control Number 1205-0NEW. Note: Please do not return the completed ETA Form 671, Part IA to this address.

Page 7 of 7