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