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On the Job Training Pre Award Survey <br />BUSINESS NAME: Americare Respiratory Services Inc STATE TAX LD. # 236-6251-3 <br />ADDRESS: 1920 E Deere Ave._ Suite 110 FEDERAL TAX LD. # 20-0029841 <br />Santa Ana. CA 92705 <br />YES NO <br />1. The business does provide worker's compensation coverage. ® Q <br /> Policy Number: VGMD1011 G1824-8 <br />2. The business does provide General Liability Insurance in the amount of ® ? <br /> One Million Dollars ($1,000,000). Policy must identify the City of Santa Ana as <br /> the certificate holder. <br />3. The system used for business accounting does document cash received, state and ® ? <br /> federal tax withholdings, FICA deductions. <br />4. The business has not been cited for any health, safety, wage and hour, or child ® ? <br /> labor violations during the past 12 months. <br />5. The business maintains a grievance and/or complaint handling procedures for ® ? <br /> employees. <br />6. The prospective OJT client is not a former employee of the business. ® ? <br />7. Wages for the planned OJT position are wages comparable to similar positions. ® D <br />8. A written job description for this position is on file. ® Q <br />9. Union concurrence has been obtained. ®NA ? ? <br />10. Business license is current. ® ? <br />1 1. The business has not had any employees laid off in the past 6 months. ® ? <br />12. The business is financially stable and has the means to train and pay for the ® O <br /> prospective OJT employee. <br /> The employer stipulates and agrees by signing below that the establishment in which on-the job <br /> training will be given: <br /> (1) Has not been moved from any previous location less than 120 days prior to the effective date of the <br /> OJT contract. <br /> (2) Is not a branch, affiliate or subsidiary of a business entity in another location which has, at any time <br /> subsequent to the date of the OJT contract, relocated or expanded so as to cause an increase in <br /> unemployment or the closing down of operations in which the entity conducts business operatio ns. <br />TOTAL WORKFORCE # <br />CONTRACT RECOMMENDED YES ® NO ? <br />Title <br />a e Mana ate <br />Program Supervisor/Director Date