Apprentice Intake Form (Other) Apprenticeship Programs at SUNY

This form is to provide SUNY with details on participants that will be served by Apprenticeship Programs at SUNY. This form must be completed in its entirety as an incomplete form cannot be saved and returned to at a later time. Please forward questions or request for additional information to: apprenticeship@suny.edu.

SUNY FOLLOWS OCCUPATION TRADE TITLES AMONG ADVANCED MANUFACTURING, HEALTH CARE/HUMAN SERVICES AND OTHER (EXCLUDING CONSTRUCTION) SECTORS. PLEASE ENSURE YOU ARE COMPLETING THE CORRECT FORM THAT ALIGNS WITH THE SECTOR AND TRADE TITLE.

Enter Today's Date as YYYYMMDD

Please note, all dates will be entered as YYYYMMDD with no "/" or "-" between the numbers.

Agreement #

Select agreement number in the dropdown.

There is a search option available to locate appropriate agreement number

Participant Last Name

Do not use all capital letters.

Participant First Name

Do not use all capital letters.

Street

City

Zip Code

Enter the basic five-digit code only. Do not use the zip+4 format. (i.e. 12077 or 13501)

In What State Does the Participant Live?

Participant Social Security Number

The purpose of this disclosure is to assist SUNY and its Partner Agencies in obtaining and reporting required information, including wage and employment data, to track the long-term success of this program. Your personal information is kept confidential and secure.

Although you cannot be denied service for failure to provide your Social Security Number, we strongly encourage you to do so in order to enable the project to quantify specific employment-related outcomes.

Enter number in the following format with no dashes 333224444. If you elect not to submit your social security number please enter 999999999.

Is Participant a U.S. Citizen?

1-Yes

0-No

1

0

Participant Phone Number

Enter phone number in the following format 555-555-5555. If number not available please enter N/A.

Participant Email Address

If no email address please enter N/A.

Participant's Date of Birth

Enter as YYYYMMDD.

Is the Participant Hispanic/Latino?

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant American Indian/Alaska Native?

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant Asian?

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant Black/African American?

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant Native Hawaiian/Other Pacific Islander?

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Is the Participant White?

1-Yes 0-No 9-Participant Did Not Self Identify

1

0

9

Please Select the Sex of the Participant

1-Male

2-Female

9- If Participant Did Not Self-Identify or Identifies as "X" Other Gender Identity.

1

2

9

Is the Participant a Veteran or an Active Service Member?

Record "1" if the participant is a person who served on active duty in the armed forces and who was discharged or released from such service under conditions other than dishonorable. A person who is on active duty is in the military full time. They work for the military full time, may live on a military base, and can be deployed at any time.

An individual in the Reserve or National Guard is not full time active duty military personnel, although they can be deployed at any time should the need arise.

Record "0" if the participant does not meet the condition described above.

Record "9" if participant does not disclose veteran status.

1

0

9

Select the Highest Educational Level or Credential the Participant had Completed at Program Entry?

1-Attained secondary school diploma

2-Attained secondary school equivalency (GED/TASC)

3-Participant with a disability received a certificate of attendance/completion as a result of successfully completing an Individualized Education Program (IEP)

4-Completed one of more years of post-secondary education

5-Attained a post-secondary technical or vocational certificate (non-degree)

6-Attained an Associate degree

7-Attained a Bachelor's degree

8-Attained a degree beyond a Bachelor's degree

0-No higher education completed

Select College Where Related Instruction will be Provided.

Name of Employer

If the employer name is not located in the dropdown list, ensure the trade the participant is pursuing is within this SUNY sector.

Click here for a comprehensive Occupation by Sector Chart. Please email apprenticeship@suny.edu if an employer name needs to be added.

Employer Address

If listed employer in the above question, provide address of employer.

If Employer is Signatory to Group Sponsor, Select Group Sponsor Name From List.

If the group sponsor name is not located in the dropdown list, please email apprenticeship@suny.edu to request it be added.

If employer is sponsor leave blank.

Participant Wage

Enter wage of participant at employer listed above prior to training. May be entered as hourly or annual. Indicate N/A if participant wage is unavailable.

(i.e. $15.00/hourly or $50,000/annual)

Employment Start Date

Enter as YYYYMMDD or "N/A"

Select Apprentice's Trade from List.

NYS apprenticeable trades: https://labor.ny.gov/apprenticeship/general/occupations.shtm

If trade name is not located in dropdown list, please check that you are inputting this apprentice in the correct sector sheet.

Minimum Journey-Worker Rate

This is minimum rate an apprentice could receive following completion of the Apprenticeship and issuance of the Journey-Worker card. Enter rate from AT401 - question #7. Leave blank if unknown.

Name of Person Entering Data on this Form

Enter as First Name Last Name.

Person Entering Data on this Form's Phone Number

Enter phone number in the following format 555-555-5555.

Person Entering Data on this Form's Email

Signed Information Release Form

Each participant must sign a Participant Information Release Form.

Check this box to certify it has been signed and attached.

Please attach the signed "Participant Information Release Form" and as available the AT401. Please save as a single PDF and use the file naming convention "date_participantlastname_release.pdf" such as "20200312_Doe_release.pdf" (date should be date of submittal).

Drop your files here

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