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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 />111 t1l., 1/w -w y - i 11.&ov —/in d (1—(/ -21Z5. 1-11L, v <br />OJT TRAINEE TERMINATION/COMPLETION FORM <br />1. <br />Contractor Name: 1. Name of Trainee: <br />2. <br />Date of Birth: <br />3, SSN (Last 4 digits): <br />C Sex: - <br />El Male El Female <br />5 <br />Racial/Elboic Identification (Check One or More): <br />7. ferminationiCompletion Date: <br />❑ American Indian or Alaska Native ElAsian El Black or African American <br />Hispanic or Latino [I Native Hawaiian or Pacific Islander El White <br />Trade Classification of Trainee (e.g., Electrician): <br />Type of Training Program: <br />Ej USDOL Approved [I FHWA proved <br />10. <br />Total Training Hours of Program: <br />ill. Total Training Hours Completed: <br />12. <br />Termination/Completion <br />13. Reason for Termination: <br />E]Fired E]Quit [] Laid Off [I Completed Program <br />1 <br />14, <br />PREPARED BY: Signature andTille of Contractor's Representative <br />15. Date: <br />