Contractor_________________________________ ETP Agreement No.________________

 

 TRAINEE AUTHORIZATION FOR ON-LINE ENROLLMENT

 · INSTRUCTIONS FOR THE CONTRACTOR

 All trainees participating in the ETP training program must read the following Authorization and sign below before they can be officially enrolled. These original signatures must be sent to ETP within 30 days of the trainee’s enrollment date. Send to: Employment Training Panel - Fiscal Unit, 1100 J Street 4th Floor, Sacramento CA 95814.

 · TRAINEE AUTHORIZATION

 I hereby authorize the Employment Development Department (EDD) to release to the Contractor or the Employment Training Panel (ETP), Unemployment Insurance (UI) and employer reported wage data contained in my records. This authorization, in connection with the State-funded ETP Agreement, allows EDD:

 ¨         to release, upon request during the term of this agreement, any necessary information to confirm the Contractor’s compliance with the requirements of this Agreement, and

 ¨     to disclose any data required for certification and employment verification, including personal data requested which is necessary for the purposes of any and all statistical studies (which will not identify individual information) concerning ETP training, within seven (7) years after the date I signed this authorization.

 I also authorize any and all employers I am employed with during the term of this agreement, to release to the Contractor or the ETP, upon request, any necessary information to confirm the Contractor’s compliance with the requirements of this Agreement. For audit purposes, this authorization must be maintained by the Contractor for four (4) years after the end term of the Agreement or three (3) years from the date of the last payment by ETP to the Contractor, or the date of resolution of appeals, audits, claims, exceptions, or litigation, whichever is later.

 To the best of my knowledge, I certify all data supplied by me is true and complete. I understand the data requested is confidential and is protected by the Information Practices Act of 1977 and the Federal Privacy Act of 1974. I have the right to inspect my personal data by submitting a written request and proper identification to:  Employment Training Panel, Assistant Director of Administration, 1100 J Street, 4th Floor, Sacramento, CA 95814.


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TRAINEE SIGNATURE AND DATE

 

 

 

 

   

ETP 104auth (3/00)