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APPRENTICE ACTION FORM Commonwealth of Virginia Apprenticeship Program Department of Labor and Industry 13 S. 13th Street Richmond Virginia 23219 Field Rep Last Name/ DONATI Sponsor No In accordance with the Privacy Protection Act of 1973 Sections 2. 1-377-386 of the Code of Virginia you are not legally required to complete this request for information concerning your race or sex or veteran status. This information is used by the Virginia Department of Labor and Industry and the U*S* Department of Labor for statistical analysis to determine the percentage of minorities women and veterans that participate in apprenticeship training. However if you are applying for Veterans Administration VA benefits you must indicate that you are a veteran* The program sponsor and apprentice agree to the terms of the Apprenticeship Standards incorporated as part of this Agreement. The sponsor will not discriminate in the selection and training of the apprentice in accordance with the Equal Opportunity Standards in Title 29 CFR Part 30. 3 and Executive Order 11246. This agreement may be terminated by either of the parties citing cause s with notification to the registration agency in compliance with Title 29 CFR Part 29. 6 Apprentice Name Type or print name as it should appear on completion certificate /RANK First Name Middle Initial City Address Last Name VA Zip Code Phone /MOS SSN Sex Occupation Date of Birth Veteran DOT/ONET Code Race Credit Length of Program Education Level Starting Date Estimated Completion Date Hours - Probation Hours Name Location Where Attained If Credit Given Previously Registered as an apprentice with the State of Virginia only Yes No Name of company/sponsor Related Instruction will be covered through Apprentice Wages For Related Instruction Number Hours Per Year Will Not Be Paid Signature of Apprentice Date Competency X Time Based Signature of Parent/Guardian if minor Hybrid YOUR EMAIL Name of Sponsor Representative City/County Fax PLEASE CHECK IF THIS IS A 1LT ROBERT BRYAN HICKS FIPS State Email REGISTRATION SUPERSEDING AGREEMENT REINSTATEMENT STUDENT H. S* CODE COMMUNITY COLLEGE CODE Journeyworker s Hourly Wage Apprentice s Entry Hourly Wage WAGES Term Hrs Wage Rate Mark One Period 1 Date Signed Registered with the Virginia Department of Labor and Industry Name and Address of Sponsor Designee to Receive Complaints if applicable Commissioner 2 000 hours or more a letter is required COMPLETION Additional Credit Hours at time of Completion Signature of Sponsor s Representative Title Signature of Related Instruction Coordinator EFFECTIVE DATE Revised 2011 CANCELLATION Reason. 1-377-386 of the Code of Virginia you are not legally required to complete this request for information concerning your race or sex or veteran status. This information is used by the Virginia Department of Labor and Industry and the U*S* Department of Labor for statistical analysis to determine the percentage of minorities women and veterans that participate in apprenticeship training.

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