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On the Job Training Pre Award Survey <br />BUSINESS NAME: <br />ADDRESS: <br />STATE TAX I.D. # <br />FEDERAL TAX I.D. # <br />YES NO <br />1. <br />The business does provide worker's compensation coverage. <br />❑ <br />❑ <br />Policy Number: <br />2. <br />The business does provide General Liability Insurance in the amount of <br />❑ <br />❑ <br />One Million Dollars ($1,000,000). Policy must identify the City of Santa Ana as <br />the certificate holder. <br />3. <br />The system used for business accounting does document cash received, state and <br />❑ <br />❑ <br />federal tax withholdings, FICA deductions. <br />4. <br />The business has not been cited for any health, safety, wage and hour, or child <br />❑ <br />❑ <br />labor violations during the past 12 months. <br />5. <br />The business maintains a grievance and/or complaint handling procedures for <br />❑ <br />❑ <br />employees. <br />6. <br />The prospective OJT client is not a former employee of the business. <br />❑ <br />❑ <br />7. <br />Wages for the planned OJT position are wages comparable to similar positions. <br />❑ <br />❑ <br />8. <br />A written job description for this position is on file. <br />❑ <br />❑ <br />9. <br />Union concurrence has been obtained. []NA <br />❑ <br />❑ <br />10. <br />Business license is current. <br />❑ <br />❑ <br />11. <br />The business does not have a history of failing to provide OJT participants with <br />❑ <br />❑ <br />continued long tern employment. <br />12. <br />The business has not had any employees laid off in the past 6 months. <br />❑ <br />❑ <br />13. <br />The business is financially stable and has the means to train and pay for the <br />❑ <br />❑ <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 operations. <br />TOTAL WORKFORCE# <br />Employer Title Date OJT Coordinator/Case Manager Date <br />Carlos de In Riva Date <br />Economic Development Specialist <br />CONTRACT RECOMMENDED: YES ❑ NO ❑ <br />Date <br />Rev. 8/2012 <br />