Fill out the following form to have your Registered Apprenticeship Program included on the Eligible Training Provider List (ETPL). Please complete one form per occupation you would like to register on the ETPL. Completed forms can be submitted by either: Online form below Print, Scan and email to Amy.Beller@iwd.iowa.gov Mail the below form to: Amy Beller, Registered Apprenticeship Program Coordinator, 1000 East Grand Avenue, Des Moines, IA 50319 Registered Apprenticeship Sponsor Registered Apprenticeship Sponsor Name Federal Employer Identification Number (FEIN) Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Website Address Website Address Phone Number Email Address Occupation(s) that are registered with the DOL / Office of Apprenticeship Number of Active Registered Apprentice(s) Disability Access - Select -YesNo ADA Compliant - Select -YesNo Financial Aid Available - Select -YesNo Programs On Another State's ETPL - Select -YesNo Related Training Instruction (RTI) Provider Complete the section below if the Registered Apprenticeship Sponsor does not provide related training instructions for the Registered Apprenticeship Program. Name of Related Training Instruction (RTI) Provider Address of Related Training Instruction (RTI) Provider Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Cost of Instruction Method of Instruction Length of Instruction in Weeks Certification I certify that our Registered Apprenticeship Program may be included on the ETPL and further certify the information contained in this application is true and correct. All supporting documentation is true and factual. Sponsor Name First Name Last Name Sponsor Title Signature Sign above Date Date: Date For questions regarding registration, please contact:AMY BELLER Registered Apprenticeship Program Coordinator 515-725-1035 amy.beller@iwd.iowa.gov
