DTG Participation Agreement

Permanent Address *

If permanent address is same as mailing address, check box and skip this section.

City * State *

Zip Code *
(format: 55406 or 554061234)

Highest level of education attained prior to beginning the dual training program *
High School/GED
Post-Secondary Certificate
Associate's Degree
Bachelor's Degree
Other (Please Specify):

Select all Related Instruction Training Providers you will be attending under the dual training program *
(select up to 7)

Demographic Information

The following information will help the Office of Higher Education evaluate program success, it will not be used as a basis for program eligibility. Providing this information is voluntary.

Are you Hispanic or Latino? (i.e., a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture, regardless of race)
Yes
No

	American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.
	Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
	Black or African American A person having origins in any of the black racial groups of Africa.
	Native Hawaiian or other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
	White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Are you currently serving on active duty in the U.S. Armed Forces for purposes other than training?
Yes
No

Dual Trainee Certification

	I have read and understand the Notice to Dual Trainee.
	I certify that upon completion of the dual-training program, I will earn one or more industry-recognized degree, certificate, and/or credential.
	I understand and accept the obligation to contact the Office of Higher Education of any changes in information provided on this form.
	I give permission to the Office of Higher Education; my employer or organization (the grantee); and my Related Instruction Training Providers (listed on form) to share information and documentation with each other as pertains to the Dual Training Grant program. This may include, but is not limited to, related instruction bills, schedules, and grades; and employment titles, wages, and average hours worked per week.
	I understand that participation in this program is subject to the availability of funds. I may be responsible for any costs incurred with my Related Instruction Training Provider, if not paid by my employer and/or the Dual Training Grant.
	I certify that the information on this application is true and correct and I promise to provide additional documentation if requested. I understand that this form is used to establish eligibility for the Dual Training Grant program and if I purposely give false or misleading information on this form, I may be subject to a fine, prison sentence or both; and such action may result in the forfeiture of future participation in this program.

Dual Trainee Participation Agreement

Agreement Information

Demographic Information

Dual Trainee Certification