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Program Registration and U.S. Department of Labor
<br />Apprenticeship Agreement Employment and Training Administration
<br />Office of Apprenticeship
<br />.._ does; not constitrtte r Title 29, T � - ..0
<br />f�EDfwTfATtt�W'-�;aEGTNOf"d P(I � OMB No 1205 0223 Expires„ 1131/202
<br />Warning:This agrrerntant of ti � a certification rxnde .. Title 29 Code of Federal Regulations (CFR) Part 29 sets forth labor standards to
<br />Ci R, Part ra for tine employment of file apprentice on Federally financed or safeguard the welfare of essr ated construction projects, 8ss, Current cafrBifiratiorls must be obtainet9 apprentices and extend the application of such standards
<br />from the Office of Apprehticesitip (fOA) or the recognized State by prescribing policies and procedures concerning registration. This collection
<br />Apprenticeship Agency shown Below. (lt6m 24) instrument has two sections, one for program sponsor's Information (Section 1)
<br />and one for apprentice's information (Section 111).
<br />1 (Last, Name „ Fars MPt ETBD f3"f AS 1FE fi rl fIOT' TO ,PDNSpR. PART SHC}DefinONLitions , reverse)D ODD RY AS PREC�TtCB'
<br />t, Middle) and Address µµµ Veteran Status .�_ ..
<br />MURRY, ROOSEVELT 4. a. Ethnic Group
<br />faarticipant did not self-€den1y Non Veteran
<br />4008 ST. ANDREWS C1R APT 2D b Race
<br />MISHAWAKA. IN. 46545 _........ _.. _..... ........................
<br />2. Date of Birth (Mo., Day, Yr.)
<br />3/26/1980
<br />B. Education Level
<br />_ ........_. _.._......... Black or African American GFa
<br />3. Sex (Mark one)
<br />Male
<br />7a. Employment Status New Employee
<br />76 Careern anverse) None
<br />„Connection Pirns�tkuctions o.. ..
<br />ui a4pprenuce
<br />Data 9. Signature of ParenilCsua — -�r _..._.�
<br />rdian of minor) Data
<br />PARrs:spousom EXCEPT FOR ITEMS 8, 7, 8,10a. -10C, REMAIN[
<br />I. Sponsor Program No, IN010950002
<br />Sponsor Name and Address (No. Street, City, County, State, Zip Cade)
<br />Plasterers & Cement Masons #692 J.A.T.C,
<br />220 N. FULTON STREET
<br />INDIANAPOLIS, IN, 46202
<br />F ITEM REPOf RJI LAATEt3 FRom PR GRAM REGISTRATION.
<br />.. _.
<br />t'a 0ccupatton (The work processes listed in �� O on Code: 0075 V1
<br />Interim V
<br />he standards are eaa1 of this agreement). .
<br />Credentials
<br />Only applicable to Part s,
<br />CEMENT MASON 3,b. and 3.c.
<br />JAOpcnc elation Training 4, Term (Hrs.) f„ Prohanonary Perind (Hrs.)
<br />T€me-Based 5600 1000
<br />iT-rExperience Preµ a (Hrs.} g 8. Date Apprenticeship
<br />f ous 160015 � Remain€ W Begins
<br />P (Hrs. n ate ...`.�...�..__
<br />4000
<br />9a. Related Instruction
<br />ppr®ntice —W
<br />ag
<br />a s`—ior Re. w
<br />d�^W.n fInstruction ,elated Traaig Instruction _Source
<br />432 hours TotalT1_N1_-__11_
<br />CEMENT LOCAL 692 JATC
<br />—..
<br />1. Wages: jInstructions on reverse) 10a. Pre-Apprenticeship
<br />Hourly Wage $24.20
<br />pp ntice's Ent Hourly 4.20 10e. Journeyworker's Hourly Wage $38.78
<br />10d. Term IJ
<br />. m _......,_ _..... 5600 800800 800 800 5600
<br />90e, e ffafe ...�..—.....0 800 800
<br />� .,....... ...—..
<br />_ .
<br />fAfag_.�._ -_ m.,.._._ e__ .....�.,..
<br />0
<br />Percent 60% 75% 80 70% %a 85% 90% 95% 100 /o
<br />Hourly _.._....
<br />11, Siglarttt e of afrcarfsrr l raiares rdtative(s) YDate Signed �.. 11, Name and Address of Sponsor Designee to Receive Complaints
<br />✓ (if applicable) PATRIiCK HANSEN
<br />125 gnature f Sponsors Re resentahve��._m_.
<br />220 N. FUL'rON STREET
<br />p O Date Signed
<br />INDIANAPOLIS, IN. 46202
<br />..,..,�,,.......�,.. ,.:,.ur 111 n e:,tar. p r d"KM a raJ't4a ar�1.31'. r+i.S.e'k''....................�.,......_.....,......�.„_.�„..,... ..__..._,.m....'�.�.. .,.. ,.� �.
<br />1. y and Re istratlon Agency an _g g g ncy Address 2. Signature (Registration Agency)
<br />Office of Apprenticeship USDOL 9 y) IDate Registered
<br />... oufh ren Bend, IN,, 46628 7900 _ Kathleen Sokolowski 9/15/2015
<br />4. w
<br />Identification Numberon on reverse): IN15NO7110
<br />,ice...... Definiti....._ _..._ u _ ..�.,.....�.-�
<br />Page 1 of 3
<br />ETA 671 — Section 11 (November 2014)
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