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INDIANA DEPARTMENT OF TRANSPORTATION <br />ECONOMIC OPPORTUNITY DIVISION <br />100 North Senate Avenue <br />Room N750 <br />Indianapolis, Indiana 46204-2216 <br />Telephone: (317) 233-2412 Fax: (317) 233-0891 <br />i11141�1%raITvITly oda e 1lAn:4Bold?7 ,Irol:o <br />OJT TRAINEE INTRODUCTION FORM <br />1. <br />Contractor Name: 2. Address: <br />3. <br />Name of Trainee: 4. Trainee Address and Telephone Number: <br />5. <br />Date of Birth (MM/DD/YYYY): 6. SSN (Last 4 digits): 7. Employee Status (Check One): <br />❑ New Hire ❑ Rehire <br />8. <br />Racial/Ethnic Identification (Check One or More): 9. Gender: <br />❑ American Indian or Alaska Native ❑ Asian ❑ Black or African American ❑ Male ❑ Female <br />❑ Hispanic or Latino ❑ Native Hawaiian or Pacific Islander ❑ White <br />10. <br />Hire/Rehire Date: 11. Previous Training Hours (Enter "N/A" if Not Applicable): <br />12. <br />Does Trainee Have Any Experience Performing Work Stipulated Under the Approved Program? <br />❑ Yes ❑ No If yes, briefly summarize <br />13. <br />Trade Classification of Trainee: <br />14. Type of Training Program: <br />❑ Carpenter ❑ Cement Mason ❑ Electrician <br />❑ Equipment Operator ❑ Iron Worker ❑ Laborer <br />❑ USDOL Approved ❑ FHWA Approved <br />Mechanic ❑ Millwright ❑ Painter <br />❑ Pipefitter/Plumber ❑ Truck Driver <br />15. <br />Total Training Hours of Program: <br />16. How Was Trainee Referred? <br />❑ Union ❑ Minority/Women Organization <br />❑ Employment Agency ❑ Other <br />17. <br />Has Trainee Received Copy of Training Program? <br />18. Union Affiliation (Enter "N/A" if Not Applicable): <br />❑ Yes ❑ No <br />Union Trade Name: <br />19. <br />PREPARED BY: Contractor's Representative Name, Title, and Signature <br />20.. Date <br />Signature: Printed Name and Title: <br />.I III N ,A cy T - <br />2L <br />Approved Denied Reason for denial: <br />22. <br />INDOT Representative Name and Signature: <br />23. Date <br />Signature: Printed Name: <br />