TRAINING TRUST PRE-AUTHORIZATION FORM (41)

Participant to complete parts A & B

 

PART A

 

Name _______________________________________________________ Date ___________________

 

Address _____________________________________________________________________________

 

City _________________________________________________ State __________ Zip ____________

 

Telephone (home) _________________________________ (work) ______________________________

 

Employer ______________________________ Site ______________ Work Shift & Hours __________

 

Have you taken this class before?          � yes                 no

 

Eligible Participant                                  yes                no

 

    Stationary Engineer     Custodial Engineer  Other Skilled Occupation  ________________

 

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PART B

 

Training Institution __________________________________________________________________

 

   Public School    Private    School Seminar    Specialty Training

 

Class Title _________________________________________________________________________

 

Estimated Cost of Tuition or Class Fee @ 100% $ _____________________

 

Estimated Cost of Materials @ 75%                   $ _____________________

 

Estimated Travel Cost (if applicable)                  $ _____________________

 

Class Starting Date ________________________ Time Starts ____________ Ends _________

 

Class Ending Date ________________________________ Total Class Hours _____________

 

Circle Class Day(s):  Monday   Tuesday   Wednesday   Thursday   Friday   Saturday

 

By signing this form the applicant acknowledges a pre-determination procedure is set in motion for a benefit provision and further acknowledges receipt of the appeals procedure located on the back of this form.

 

Name _______________________________________  Date ______________________

 

Send Completed form to: Fax 253-351-0639 or

Mail to:             Western Washington Stationary Engineers Training Trust

                        Joint Apprenticeship & Training Committees

                        18 E Street SW

                        Auburn, WA 98001-5256