On-The-Job Training Employer Information Form
Date ________________
Name of Firm ____________________________________________DBA ________________________________
Address _____________________________ City _______________________State _____ ZIP_______________
Contact Person _________________________________Phone____________________FAX_________________
E-Mail ______________________________________________________________________________________
IRS Federal ID# ___________________________Unemployment Insurance #______________________
Type of Organization Public Proprietorship Partnership Corporation Private Non-profit
Other _________________________________
Are you an Equal Opportunity Employer? Yes No
How long have you been in business in this area? _____years
What is your chief product or service? _____________________________________________________________
How many employees do you have? ________ Full-time ______ Part-time
Number of employees on lay-off? ________
Are employees on lay-off in the proposed hiring categories? Yes No
What job titles/job descriptions will need to be filled? (Attach job descriptions, if available)
Are jobs expected to last a year or more in the normal course of business? Yes No
Are any of these jobs covered by a collective bargaining agreement? Yes No
If so, obtain and attach a “concurrence letter” from the union (s)
Are any workers currently on strike or lockout or lay-off? Yes No
Do you use a staffing agency? Yes No If so, which one? __________________________
Describe the relationship: ________________________________________________________________
Is the pay of any job based upon commissions, tips, piecework or incentives? Yes No
If so, please explain: ____________________________________________________________________
What fringe benefits are provided to regular employees? ______________________________________________
When are benefits made available to employees? ____________________________________________________
Assurances and Compliance Items
Do you have a payroll system that records all pay checks and amounts? Yes No
Can the local workforce agency verify wage payments quickly onsite? Yes No
If not to either, how will wages be verified for OJT payments? __________________________________________
What is your estimated turnover rate? _____
What is your Workers’ Compensation carrier (or an equivalent system)? __________________________
Will OJT trainees be covered? Yes No
Are any of the jobs considered for an OJT to be filled by “independent contractors” or individuals not employed by
your firm during the entire training period? Yes No
Are there any outstanding wage and hour, health and safety, or discrimination complaints or adverse decisions?
Yes No If so, within how many years? _______________________
Has your company relocated from another area in the U.S. within the last 120 days, leaving any workers behind?
I certify that the above information is, to the best of my knowledge, true and correct:
Local Workforce Agency:
Authorized Signature Date
Authorized Signature Date
Print Name and Title
Print Name and Title
Staffing Agency (if applicable):
Reviewed By:
Authorized Signature (if applicable): Date
Authorized Signature Date
Print Name and Title (if applicable):
Print Name and Title