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FUNDING SOURCE <br />Dislocated Worker <br />Adult <br />�! Other <br />DATE <br />AGREEMENT# <br />SANTA ANA WORK CENTER INVOICE <br />CITY OF SANTA ANA <br />OJT INVOICE <br />DURATION OF <br />AGREEMENT: From: <br />INVOICE # <br />To: <br />INVOICING PERIOD: From: To: <br />NAME OF TRAINEE: CASE #: <br />NAME OF EMPLOYER: <br />ADDRESS: <br />PHONE #: <br />MAXIMUM <br />TRAINING HOURS: <br />am <br />ZIP: <br />OJT MAXIMUM <br />REIMBURSEMENT AMOUNT: <br />COST CATEGORY <br />HRS. INVOICED <br />TO DATE <br />HRS. INVOICED <br />THIS PERIOD <br />TOTAL HRS. <br />INVOICED <br />EMPLOYER SIGNATURE <br />REMAINING BALANCE <br />OJT HOURLY REIMBURSEMENT <br />REIMBURSEMENT THIS PERIOD <br />OJT COORDINATOR SIGNATURE <br />DATE DATE <br />H;/Acctg Form White — Purchasing/ Canary — WIA Fiscal / Pink— Program Operator / Goldenrod — Employer <br />Revised 1/12/10 <br />