CSTB Local Incumbent Worker Training (IWT)

1. Company Information

Please select any applicable options
Veteran owned
Native-American owned
Asian-American owned
Hispanic-American owned
African-American owned
Women-owned
The company is located in:
Distressed inner-city area
Rural County/Rural Area
HUB Zone
Brownsfield Resolution
Enterprise Zone

2. Training Information

Please provide the following information regarding the individuals and costs of the proposed training. Insert additional rows as needed. Maximum per company is $50,000. Maximum per trainee is $3,500. Training must be completed within 6 months of date of approval.
Minimum requirements: Must be Hillsborough County resident, 18 years and older, and a 6 month company employee. An I-9 Form must be submitted.
Job Title of Individual(s) Receiving Training Number Receiving Training Avg. Rate of Starting Wage Est. Rate of Pay Post-Training Training Provider Type of Training – Course Name Training Estimated Start Date Training Estimated End Date Certificate Issued/Recognized By: Certification Name: Classroom/ Training Hours Actual Cost of Training/Tuition per Individual

3. Training Provider Info

Based on your organization’s structure, please complete either the Employer Respondents OR Public Institutions of Higher Learning & Entities that carry out programs under the National Apprenticeship Act section below.
Employer Respondents: For each educational institution proposed to provide training, list the following information:
Training Provider Name Contact Person Physical Address Phone Email Address Institution Web Address The training provider will be Training will be delivered
Public Institutions of Higher Learning & Entities that carry out programs under the National Apprenticeship Act: List the following information for each employer you expect to participate:
Business Name Contact Person Address Phone Email Address Number of Employees Anticipated to Participate

4. Budget

Employer non-Federal Contribution -% of Cost Employers # of Employees Careersource Tampa Bay Contribution
At least 10% Employers with 50 or fewer employees 90%
At least 25% Employers with 51 - 100 employees 75%
At least 50% Employers with more than 101 employees 50%

Maximum training hourly wage allowed is $35.00/hour if training is provided by internal employee and $200/hour if training is provided by non direct employee.

5. Anticipated Outcomes

Please check the boxes that apply to the anticipated outcomes of the proposed project.
Will improve the long-term wage levels of trainees
Will create new jobs within our company
Will save jobs within our company
Will promote employees within our company
Will enable employees to receive certifications or credentials
Will increase the efficiency of our company
Will enable our company to gain more business
Will lower employee turnover in our company
Critical to the short-term viability of our company
Will assist in the training of veterans
Will assist in the training of the disabled
Will increase the profitability of our company
Will improve the short-term wage levels of trainees
Would help prevent company from having to relocate operations
Critical to the long-term viability of our company
Will make this location more competitive within company
Will assist in the training of minorities
Will assist welfare to work participants
Important to the stated mission of our company
Will be an important component of our company’s overall workforce employee development efforts
Will assist in the improvement of international trade opportunities

6. Certification by Authorized Company/Institution Representative

NOTICE OF CONFIDENTIALITY OF INFORMATION
To the extent feasible and permissible by law, CareerSource Tampa Bay (CSTB) will honor an applicant’s request that confidential information submitted to CSTB will remain confidential. CSTB will treat the information confidential only if: (i) the information is in fact protected confidential information such as trade secrets or privileged or confidential commercial or financial information, (ii) the information is specifically marked and identified as confidential by the applicant, (iii) the information is segregated and placed in a separate appendix to the application, and to the application, and (iv) no disclosure of the information is required by law or judicial order. If the application results in a grant, the honoring of the confidentiality of the identified data shall not limit CSTB’s right to disclose the details and results of this award to the public.

MANAGEMENT CERTIFICATION I hereby certify that I have read the foregoing application and that the information contained herein is true and accurate to the best of my knowledge and belief. Furthermore, to the best of my knowledge and belief, our company and/or organization does not have any outstanding liabilities to the State of Florida. I am aware that any false information or intended omissions may subject me to civil or criminal penalties for filing of false public records and/or forfeiture of any training award approved through this program.

TERMS, CONDITIONS & ASSURANCES CERTIFICATION
I hereby certify that I have read the terms, conditions and assurance posted on the CareerSource Tampa Bay website, and if awarded an Incumbent Worker Training Grant, I certify and hereby agree that our company and or/organization will abide by them for the term of the grant period.

Typing in your name serves as your electronic signature.

Name and Electronic Signature:
Title:
Email Address:
Today's Date:

Equal Opportunity Assurance Statement

As a condition of the proposal for this grant, the Applicant assures that it will comply fully with the nondiscrimination and equal opportunity provisions of the following laws:

1. Section 188 of the Workforce Investment Act of 1998 (WIA) which prohibits discrimination against all individuals in the United States on the basis of race, color, religion, sex, national origin, age, disability, political affiliation, or belief, and against beneficiaries on the basis of either citizenship/status as a lawfully admitted immigrant authorized to work in the United States or participation in any WIA Title I B financially assisted program or activity;

2. Title VI of the Civil Rights Act of 1964, as amended, which prohibits discrimination against qualified individuals with disabilities;

3. Section 504 of the Rehabilitation Act of 1973, as amended , which prohibits discrimination against qualified individuals with disabilities;

4. The Age Discrimination Act of 1975, as amended, which prohibits discrimination on the basis of age; and

5. Title IX of the Education Amendments of 1972, as amended, which prohibits discrimination on the basis of sex in educational programs.

The Applicant also assures that it will comply with 29 C.F.R. Part 37 and all other regulations implementing the laws listed above. This assurance applies to the grant applicant's operation of the WIA Title I — financially assisted program or activity. The Contractor understands that CSTB and the United States has the right to seek judicial enforcement of the assurance. By signing above, the Applicant certifies and assures that it will fully comply with the applicable assurances outlined above.

7. File Uploads

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