Registered Apprenticeship Incentive Program
                             Grant Application

Company Name:                                                         Type of Business:
Company Contact Person:                                               Telephone Number:
Company Address:
City:                                State:                           Zip Code:
Number of Employees:
Federal Employer Registration Number:
North American Industry Classification (NAICS):

Name of Apprentice:
Apprenticeable Occupation:
Date Employee Started Apprenticeship:

Attach a copy of the approved Apprenticeship Standards/Apprenticeship Agreement
Joint Approval form and accompanying Work Process Schedule for the apprentice.

Indicate the appropriate Grant Request:

                       (Check only one box.)
    $2,500 Grant Request for 26-Week Apprenticeship Period                   □
    $2,500 Grant Request for 52-Week Apprenticeship Period                   □

By means of endorsement of this document, the grant applicant certifies the following:

    •   The employee for whom an incentive is requested is currently employed in an approved
        Bureau of Apprenticeship & Training registered apprenticeship;
    •   No other state or federal financial assistance has been received for the registered apprentice
        during the period applicable to this grant application. (State financial assistance from the
        Business Relocation Assistance Grant Program or the Business Employment Incentive
        Program administered through the New Jersey Economic Development Authority is exempt
        from this prohibition);
    •   The grant funds will be used to offset training costs associated with the registered
    •   The employer intends to have the registered apprentice complete the full term of the
        apprenticeship training period. (Future grants under this program will be contingent upon the
        retention of apprentices assisted under the program);
    •   Grant funds will be primarily used to train individuals working in the production of goods;
    •   The employer is not in violation of any applicable federal or State laws and regulations,
        including but not limited to: taxes, child labor, wages and workplace standards. Further, all
        unemployment/disability insurance contributions, assessments, penalties, fees and/or back
        wages due or established by the New Jersey Department of Labor & Workforce Development
        have been paid in full;
    •   The employer agrees to: cooperate with any monitoring, evaluation, and/or audit conducted
        by the Department of Labor and Workforce Development or their designees and authorized
        agents; provide full access to their books and records; provide access to any audit report or
        review which coincides in whole or in part with the period of the grant; maintain its records
        and accounts in such a way as to facilitate the preparation of financial statements in
        accordance with generally accepted accounting principles and the audits there of; be
        responsible for any disallowed costs resulting from any audit exceptions incurred by its own
        organization; and
    •   All information contained in this application is accurate, complete and true.

Name and Title of Company Representative Authorized to Sign Grant Application

_____________________________________                             __________________
Signature                      Date                                      Title

Name and Title of Collective Bargaining Agent Representative for Apprenticeable
Occupation (If applicable)

_____________________________________                             __________________
Signature                     Date                                       Title

Collective Bargaining Entity:


City:                                State:                            Zip Code:

For New Jersey Department of Labor and Workforce Development use only

Grant Approved and Incentive Payment Authorized:

Commissioner – Department of Labor and Workforce Development Date

Submit Grant Application to:

                        Registered Apprenticeship Incentive Program
                 New Jersey Department of Labor & Workforce Development
                                 Office of Grants Operations
                             P.O. Box 915 Trenton, New Jersey

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