Training Provider Application – NoRTEC

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Training Provider Application

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- Step 1 of 5

General Information

Provider Name *

Provider Federal Tax ID# *

Main Address *

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone Number *

Main Contact Name *

Billing Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Billing Phone Number *

Billing Contact Name *

Mailing Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Financial Aid Phone Number *

Financial Aid Email Address *

Website / URL *

Is this entity an accredited postsecondary institution? *

Yes
No

Provider Information

Institution Type (check applicable type) *

Adult Education and Family Literacy
Apprenticeship Program
Aviation and Flight School
Community College
Cosmetology/Barber Training Provider
Four Year College/University
Graduate Programs
Hospital or Health Programs
Job Corps
Law Enforcement Academies
Private Business or Technical School
Public Adult School with Occupational Programs
Secondary Schools
Technical College Campus
Trade School
Two-Year, Technical and Community College
Other Education and Training Institution

Type of Entity (select one) *

Higher Ed: Associates Degree
Higher Ed: Baccalaureate or Higher
Higher Ed: Certificate of Completion
National Apprenticeship
Private Non-Profit
Private For- Profit
Public

Americans with Disabilities Act (ADA) Compliant *

Yes
No

Institution Description (keep description brief) *

Accreditation *

Yes
No

Accrediting Body (check all applicable) *

Bureau for Private Postsecondary Education (BPPE)
BPPE Exemption (exemption letter required)
California Department of Education (CDE)
Nonpublic, Nonsectarian School/Agency certified by CDE
Northwest Commission on Colleges and Universities (NWCCU)
Private School w/ current Private School Affidavit filed with CDE
WASC – Accrediting Commission for Community and Junior Colleges
WASC – Accrediting Commission for Schools
WASC – Senior College and University Commission
Eligible Provider under Title II of WIOA

Services Available (check all applicable) *

Career Assessment
Career Counseling
Job Placement Assistance Available
Tutorial Services Available
ESL Courses Available
GED Assistance Available
On-Site Child Care Available
Financial Aid Available
Online Registration Available

Is this entity PELL Grant (Higher Education Act) eligible? *

Yes
No
Pell Grant Not Applicable

By entering my name below, I acknowledge and affirm that the information I have provided in this form is true, accurate, and correct to the best of my knowledge and belief. I acknowledge that providing false or misleading information may lead to the rejection of this application and the potential disqualification from future application opportunities.

Name of Provider Representative *

First

Last

Title of Provider Representative *

Date *