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ETPL POLICY AND PROCEDURES <br />ATTACHMENT 4 <br />CA ETP ASSURANCES FORM <br />A completed and signed California (CA) Eligible Training Provider (ETP) Assurances Form must be <br />uploaded to the documents section of the Provider Profile in CalJOBS. This form must be uploaded <br />annually, prior to the provider being reviewed for eligibility. <br />Part A. <br />I certify that [Insert Name of School/O[ganization]: <br />(a) Is a legal entity, registered to do business in the state of California (CA). <br />(b) Has not been determined to be ineligible to receive federal funds. <br />(c) Is in compliance with Workforce Innovation and Opportunity Act Section 188 and Title 29 Code <br />of Federal Regulations Part 38. <br />(d) Has demonstrated effectiveness in operating occupational classroom or distance training <br />program(s). <br />(e) Agrees that training provider facilities, classroom instruction, relevant financial records, and <br />attendance records may be reviewed by state, federal and/or local monitors or auditors to <br />ensure compliance with funding requirements. <br />Part B. <br />I certify that I: <br />(a) Have reviewed the annual student data reporting requirements for the Eligible Training <br />Provider Performance Report (ETP Report) established for training providers. Please refer to the <br />ETP Report Required Data listed below. <br />(b) Will begin collecting required student data elements that are not currently being collected. <br />(c) Will report and submit the ETP Report data for all students trained in each of my <br />school/organization's training programs listed as approved on the Eligible Training Provider List <br />(ETPL) to the Employment Development Department by the due date. <br />I understand that my school/organization's application for program approval on the CA ETPL will not be <br />processed without receiving this Eligible Training Provider Assurances Form. <br />Name of Training Provider (School/Organization) <br />Mailing Address <br />City, State, Zip Code <br />Phone Number(###) ###-#### <br />Print Name of School/Organization Representative <br />Title of School/Organization Representative <br />Signature of School/Organization Representative Date <br />WSD21-03 Page 1 of 2 <br />