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FUNDING SOURCE <br />Dislocated Worker <br />QI Adult <br />Q Other <br />TI <br />\1.1,-",1,- SANTA ANA INVOICE# <br />,x„ W R K <br />CENTER <br />SANTA ANA WORK CENTER INVOICE <br />CITY OF SANTA ANA <br />OJT INVOICE <br />DURATION OF <br />AGREEMENT# AGREEMENT: From: To: <br />INVOICING PERIOD: From: To: <br />NAME OF TRAINEE: <br />NAME OF EMPLOYER: <br />ADDRESS: <br />PHONE M <br />MAXIMUM <br />TRAINING HOURS: <br />HRS. INVOICED <br />TO DATE <br />HRS. INVOICED <br />THIS PERIOD <br />TOTAL HRS. <br />INVOICED <br />EMPLOYER SIGNATURE <br />CASE M <br />CITY: <br />NIN; <br />OJT MAXIMUM <br />REIMBURSEMENT AMOUNT: <br />REMAINING BALANCE <br />OJT HOURLY <br />REIIMBUR EMENT I R TH THIS ERIODNT <br />OJT COORDINATOR SIGNATURE <br />DATE DATE <br />H: /Acctg form White — Purchasing/ Canary — WIA Fiscul�`iylt�—t'oplyy 0peiator / Goldenrod — F'raployer <br />Revised 1112 /10 iJ 63 <br />