SECTION 1: TRAINING PROVIDER INFORMATION
1.	Provider Name:
	Training Sites:	(Provider Application must be submitted before entering Training Sites)
	Distance Learning (WWW) Other
2.	Mailing Address:
	Address 1: Address 2: City: State: Zip: Web Site Address: http://
3.	Contact (Individual who is the primary contact for questions reqarding the application and supporting documentation):
	First Middle Last Name: Title: Phone Number: Ext. Fax Number: E-Mail:
4.	Admissions Contact (Do not complete for Apprenticeship Programs):
	First Middle Last Name: Title: Phone Number: Ext. Fax Number: E-Mail:
5.	Financial Aid Contact (Do not complete for Apprenticeship Programs):
	First Middle Last Name: Title: Phone Number: Ext. Fax Number: E-Mail:
6.	Federal EIN:
7.	Please provide a brief description of the training provider :
	Max Number of Characters: 1000     Current Number of Characters:
8.	Is this provider with the U.S. Department of Labor's Bureau of Apprenticeship and Training?
	Yes    Date registered with U.S. Department of Labor:  No
9.	Is this institution accredited?
	Yes    Accrediting Body:  No    Date of Expiration:
10.	Is this institution licensed?
	Yes    Licensing Body:  No    License Number:   Date of Expiration:
11.	Date of last financial audit:
	Auditing body:
12.	Were there any exceptions to this audit (if yes, please describe)?
	Yes  Max Number of Characters: 1000     Current Number of Characters:  No

SECTION 5: ASSURANCES
1.	Would this training provider like its home page linked to the Arzona Workforce Investment Act Statewide Consumer Report System and Eligible Training Provider List website?
	Yes    No
2.	A checkmark next to each of the following items indicates that the training provider assures that the documentation verifying the information is available upon request. Non-compliance may result in the withdrawal of certification.
	Name of accreditation and copy of license or accreditation    Outline of training program/course curriculum completed for every program offered    Criteria for "successful completion" of program/course curriculum    Proof of commercial general liability insurance Expiration Date:    Grievance Policy    Copy of most recent certified audit statement from Certified Public Accountant and explanation of any audit exceptions    ADA Compliance    Current financial statement    Unemployment Compensation and Workman's Compensation Laws    Federal Debarment and Suspension Certification    Nondiscrimination policy statement    Documentation of all previous legal actions, if any, taken against this provider, including suits, judgements, and claims    Catalogs, Brochures, Schedules, miscellaneous information    Proof that costs are customary fees in accordance with published catalogs/information    Certification of a drug-free workplace under the Drug-Free Workplace Act
3.	Regarding lobbying, the undersigned certifies, to the best of his or her knowledge and belief, that:
	No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this contract, grant, loan, or cooperative agreement he undersigned shall complete and submit standard Form-LLL, "Disclosure form to Report Lobbying," in accordance with its instructions (available from the Procurement Officer for this agreement).
	This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
4.	Authorized Signature: By signing I hereby certify that all information contained in this document is accurate as of the date of submission. I also agree to site visits and audits by the Local Workforce Investment Board or the State, and assure the provision of any and all of the above listed documentation upon request. I further certify my understanding that completion of this application does not guarantee selection as a training provider. I also understand that any or all of the items included in the application may be displayed on the Internet as part of the Arizona Workforce Investment Act Statewide Consumer Report System and Eligible Training Provider List. I understand that these requirements must continue to be met while my organization is an eligible training provider.
	Name of Authorized Official:
	Title of Authorized Official:
	Name of Organization:
	Authorized Date:	12/1/2008