Opening of Bids - Water Works North Station Well No 1 Replacement Project No 117-031R - Peerless Midwest Inc

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APPENDIX B U.S. Department of Labor Program Registration and Employment and Training Administration Apprenticeship Agreement g _ffiCe_ta At)jarenti.ceshin APPRENTICE REGISTRATION -SECTION III OMB No. 1205-022 Ex ires:01/31/2012 Warning: This agreement does not constitute a certification under Title 29,The program sponsor and apprentice agree to the terms of the Apprenticeship CFR, Part 5 for the employment of the apprentice on Federally financed or Standards incorporated as part of this Agreement. The sponsor will not discriminate assisted construction projects. Current certifications must be obtained in the selection and training of the apprentice in accordance with the Equal from the Office of Apprenticeship (OA) or the recognized State Opportunity Standards in Title 29 CFR Part 30.3, and Executive Order 11246. This Apprenticeship Agency shown below. (Item 22) agreement may be terminated by either of the parties„ citing cause(s), with notification to the registration aaencv. in comollance with Title 29. CFR. Part 29.6 PART A TO BE COMPLETED BY APPRENTICE, NOTE TO SPONSOR: PART A SHOULD ONLY BE FILLED O 1. Name (Last, First, Middle) and Address *Social Security Number Answer Both A and B (Voluntary) - _ I (Definitions on reverse) (No., Street, City, State, Zip Code, Telephone Number) 4. a. Ethnic Group (Mark one) ❑ Hispanic or Latino ❑ Not Hispanic or Latino b. Race (Mark one or more) ❑ American Indian or Alaska native ❑ Asian --•- ❑ Black or African American 2. Date of Birth (Mo., Day, Yr.) 3. Sex (Mark one) ❑ Native Hawaiian or other ❑ Male ❑ Pacific Islander Female ElWhite 7. Career Linkage or Direct Entry (Mark one) (Instructions on reverse) ❑ None ❑ Incumbent Worker ❑ Dislocated Worker ❑ Trade Adjustment Assistance ❑ Job Corps ❑ YouthBuild ❑ HUD/STEP-UP ❑ Direct Entry: 8. Signature of Apprentice 5. Veteran Status (Mark one) ❑ Non -Veteran ❑ Veteran 6. Education Level (Mark one) ❑ 8th grade or less ❑ 9th to 12th grade ❑ GED ❑ High School Graduate or Greater ❑ Post Secondary or Technical Training ❑ Adult ❑ Youth ❑ School -to -Registered Apprenticeship Date 19. Signature of Parent/Guardian (if minor) Date PART B: SPONSOR: 10. Sponsor Program No. 11a. Trade/Occupation (The work processes listed in the standards are part of this agreement). Sponsor Name and Address (No. Street, City, County, State, Zip Code 01110 Nere M1feSt; MfM 11 b. Occupation Code 12. Term 13. Probationary Period 5t'�6�bi�ust�eN�� Mrwd�ilstrfal P;irkwuri (Hrs., Mos., Yrs.) (Hrs., Mos., Yrs.) is I raka 1N 4 4 kb Wn'AL"2 3 yrs 14. Credit for Previous 15. Term Remaining 16. Date Apprenticeship Experience (Hrs., Mos., Yrs.) (Hrs., Mos., Yrs.) Begins 17a. Related Instruction 17b. Apprentice Wages for Related Instruction 17c. Related Training Instruction Source (Number of Hours Per Year) X - Will Not Be Paid Peerless -Midwest, Various Teachers and Online Education 144 18. Wages: (Instructions on reverse) 8a. Pre -Apprenticeship Hourly Wage $ Check Box Period 1 2 18d. Term X Hrs., ❑ Mos., or ❑yrs. 1000 1000 18e. Wage Rate (Mark one) % ❑ or $ X 17.66 21.97 19. Signature of Sponsor's Representative(s) 20. Signature of Sponsor's Representative(s) Apprentice's Entry Hourly Wage 18b.$ Journeyworker's Hourly Wage18c. $ 3 4 5 6 1000 1 1000 1 1000 1 1000 23.98 25.93 Date Signed Date Signed 28.01 1 29.72 7 8 9 10 21. Name and Address of Sponsor Designee to Receive Complaints (If applicable) PART Ca TO BE COMPLETED BY REGISTRATION AGENCY ,!" k' 22. Registration Agency and Address 23. Signature (Registration Agency) 24, Date Registered U.S. DOL - Office of Apprenticeship 2420 Viridian Drive - Suite G South Bend, IN 46628-7900